Individual
MR. SHANE BURGESS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
COTA/L
Contact information
Practice address
310 S EADS AVE, PARIS, IL 61944-1938
(217) 465-5395
Mailing address
3812 WESTERN AVE, MATTOON, IL 61938-2044
(217) 273-3998
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
057.002001
IL
Other
Enumeration date
07/11/2008
Last updated
07/11/2008
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