Healthcare Provider Details

I. General information

NPI: 1184905119
Provider Name (Legal Business Name): KIMBERLY ELAINE BURFORD A.B.O.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2011
Last Update Date: 09/05/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6201 FAMOUS AVE
SAINT LOUIS MO
63139-3043
US

IV. Provider business mailing address

6201 FAMOUS AVE
SAINT LOUIS MO
63139-3043
US

V. Phone/Fax

Practice location:
  • Phone: 314-600-1779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number015066
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: