Provider Demographics
NPI:1730455874
Name:BURGESS, KIRBY LEE
Entity type:Individual
Prefix:MR
First Name:KIRBY
Middle Name:LEE
Last Name:BURGESS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81134
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89180-1134
Mailing Address - Country:US
Mailing Address - Phone:702-303-7907
Mailing Address - Fax:702-982-6836
Practice Address - Street 1:2349 RENAISSANCE DR STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6191
Practice Address - Country:US
Practice Address - Phone:702-739-7716
Practice Address - Fax:702-597-2242
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner