Healthcare Provider Details

I. General information

NPI: 1073239521
Provider Name (Legal Business Name): ANTONIO O BURNS SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2022
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2216 HIGHWAY 80 E LOT 162
MONROE LA
71203
US

IV. Provider business mailing address

2216 HIGHWAY 80 E LOT 162
MONROE LA
71203
US

V. Phone/Fax

Practice location:
  • Phone: 318-307-5729
  • Fax:
Mailing address:
  • Phone: 318-307-5729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number43238060
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: