Healthcare Provider Details

I. General information

NPI: 1265930812
Provider Name (Legal Business Name): ANTWAUN BURROUGHS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

181 W VALLEY AVE STE 225
BIRMINGHAM AL
35209-3691
US

IV. Provider business mailing address

181 W VALLEY AVE STE 225
BIRMINGHAM AL
35209-3691
US

V. Phone/Fax

Practice location:
  • Phone: 205-919-3900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number775
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: