=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245255686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICKY R BURK OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/13/2006
-----------------------------------------------------
Last Update Date | 11/04/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19801 SW 72ND AVE STE 150
-----------------------------------------------------
City | TUALATIN
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97062-8347
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-691-2283
-----------------------------------------------------
Fax | 503-691-5981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1506
-----------------------------------------------------
City | CHEHALIS
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98532-0409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-242-3008
-----------------------------------------------------
Fax | 360-807-7687
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | ATI2559
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------