MEDICARE: BURGESS BROTHERS RESTAURANT LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	253Z00000X	In Home Supportive Care Agency
3	174200000X	Meals Provider

General Provider Information

NPI Number	:	1679217228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURGESS BROTHERS RESTAURANT LLC

Provider Business Mailing Address
First Line	:	6580 BELLEAU WOOD LN
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95822-5910
Country	:	US
Telephone Number	:	916-250-2761
Fax Number	:

Provider Business Practice Location Address
First Line	:	6580 BELLEAU WOOD LN
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95822-5910
Country	:	US
Telephone Number	:	916-250-2761
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	JONATHAN BURGESS
Credential	:
Telephone Number	:	916-250-2761

Provider Enumeration Date	:	04/20/2022
Last Update Date	:	05/20/2022

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Directions to “BURGESS BROTHERS RESTAURANT LLC ” Practice Location

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