Provider Demographics
NPI:1912704339
Name:BURNSIDE, TONY JR (LMT)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:BURNSIDE
Suffix:JR
Gender:
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 E DEWEY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1494
Mailing Address - Country:US
Mailing Address - Phone:269-231-0384
Mailing Address - Fax:
Practice Address - Street 1:324 E DEWEY ST STE 104
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1494
Practice Address - Country:US
Practice Address - Phone:269-231-0384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT22408522225700000X
MI7501015684225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist