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General NPI Number Information
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NPI Number | 1306224688
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Entity Type | Individual
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Provider Name | JOHN BURNSIDE JR. ATC
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Gender | Male
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Dates
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Enumeration Date | 05/07/2015
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Last Update Date | 05/07/2015
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Provider Practice Location Address
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Address Line | 777 GLADES RD
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City | BOCA RATON
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State | FL
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Zip | 33431-6424
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Country | US
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Telephone | 561-297-2044
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Fax |
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Provider Business Mailing Address
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Address Line | 1200 TALLWOOD AVE 102
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City | HOLLYWOOD
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State | FL
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Zip | 33021-7973
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Country | US
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Telephone | 561-297-3320
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AL 2282
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License Number State | FL
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