MEDICARE: SAMUEL BURLESON D.C.

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	111N00000X	Chiropractor	13208	TX

General Provider Information

NPI Number	:	1649627225
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL BURLESON D.C.

Provider Business Mailing Address
First Line	:	125 BLUE HERON DR STE B
Second Line	:
City	:	MONTGOMERY
State	:	TX
Zip	:	77316-3183
Country	:	US
Telephone Number	:	936-582-0404
Fax Number	:	936-582-0410

Provider Business Practice Location Address
First Line	:	125 BLUE HERON DR STE B
Second Line	:
City	:	MONTGOMERY
State	:	TX
Zip	:	77316-3183
Country	:	US
Telephone Number	:	936-582-0404
Fax Number	:	936-582-0410

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

Provider Enumeration Date	:	05/24/2016
Last Update Date	:	01/06/2017

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