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General NPI Number Information
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NPI Number | 1396211884
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Entity Type | Individual
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Provider Name | CAROLYN BURROUGHS OWNER
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Gender | Female
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Dates
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Enumeration Date | 10/23/2018
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Last Update Date | 10/23/2018
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Provider Practice Location Address
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Address Line | 26962 FRANKLIN RD APT 131
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City | SOUTHFIELD
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State | MI
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Zip | 48033-2437
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Country | US
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Telephone | 248-353-2100
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Fax | 248-353-2131
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Provider Business Mailing Address
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Address Line | PO BOX 2665
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City | SOUTHFIELD
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State | MI
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Zip | 48037-2665
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Country | US
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Telephone | 248-937-0917
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Fax | 248-353-2131
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | 4703119439
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License Number State | MI
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