Provider Demographics
NPI:1316292816
Name:BURRIS, BLAINE ALLEN (ATC)
Entity type:Individual
Prefix:
First Name:BLAINE
Middle Name:ALLEN
Last Name:BURRIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7344 SUNCATCHER DR
Mailing Address - Street 2:
Mailing Address - City:HANAHAN
Mailing Address - State:SC
Mailing Address - Zip Code:29410
Mailing Address - Country:US
Mailing Address - Phone:580-606-3484
Mailing Address - Fax:
Practice Address - Street 1:7344 SUNCATCHER DR
Practice Address - Street 2:
Practice Address - City:HANAHAN
Practice Address - State:SC
Practice Address - Zip Code:29410
Practice Address - Country:US
Practice Address - Phone:580-606-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11482255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer