Provider Demographics
NPI:1730626177
Name:TAMARA BURKHEAD D.C. LLC
Entity type:Organization
Organization Name:TAMARA BURKHEAD D.C. LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURKHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-875-1747
Mailing Address - Street 1:1102 W JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-2212
Mailing Address - Country:US
Mailing Address - Phone:850-875-1747
Mailing Address - Fax:850-627-3853
Practice Address - Street 1:1102 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-2212
Practice Address - Country:US
Practice Address - Phone:850-875-1747
Practice Address - Fax:850-627-3853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10451111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004395600Medicaid
FLFS194ZMedicare PIN