=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790932572
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN M BURNSIDE CMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2008
-----------------------------------------------------
Last Update Date | 08/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1208 SUNCAST LN STE 4
-----------------------------------------------------
City | EL DORADO HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95762-9666
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-941-1556
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3150 PINCHEM CREEK DR
-----------------------------------------------------
City | RESCUE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95672-9600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-363-2718
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------