MEDICARE: JODI LYNN BURCH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist

General Provider Information

NPI Number	:	1598270530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JODI LYNN BURCH

Provider Business Mailing Address
First Line	:	3701 MIRANDA AVE
Second Line	:
City	:	GILLETTE
State	:	WY
Zip	:	82718-5759
Country	:	US
Telephone Number	:	307-620-1176
Fax Number	:

Provider Business Practice Location Address
First Line	:	201 W LAKEWAY RD STE 200
Second Line	:
City	:	GILLETTE
State	:	WY
Zip	:	82718-6341
Country	:	US
Telephone Number	:	307-682-7885
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/13/2017
Last Update Date	:	12/13/2017

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Directions to “ JODI LYNN BURCH ” Practice Location

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