1407632995 NPI number — MADELEINE REGINA BURNS LM, CPM

Table of content: MADELEINE REGINA BURNS LM, CPM (NPI 1407632995)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407632995 NPI number — MADELEINE REGINA BURNS LM, CPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNS
Provider First Name:
MADELEINE
Provider Middle Name:
REGINA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LM, CPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GALLUS
Provider Other First Name:
MADELEINE
Provider Other Middle Name:
REGINA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LM CPM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407632995
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5077 N YORK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COEUR D ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-518-9327
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5077 YORK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83815-7818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-518-9327
Provider Business Practice Location Address Fax Number:
208-625-2067
Provider Enumeration Date:
08/31/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 176B00000X , with the licence number:  MID-146 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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