Provider Demographics
NPI:1043407679
Name:BURNS, VIRGINIA S (LAC)
Entity type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:S
Last Name:BURNS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-5319
Mailing Address - Country:US
Mailing Address - Phone:312-666-4600
Mailing Address - Fax:
Practice Address - Street 1:6142 ROOSEVELT RD
Practice Address - Street 2:SUITE 103
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-2311
Practice Address - Country:US
Practice Address - Phone:847-630-3968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198000480171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL198000480OtherSTATE LICENSE