MEDICARE: JASMINE BURROUGHS RD, LDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian		NC
2	133V00000X	Registered Dietitian	L005442	NC

General Provider Information

NPI Number	:	1487143244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE BURROUGHS RD, LDN

Provider Business Mailing Address
First Line	:	5015 MILLER DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-1877
Country	:	US
Telephone Number	:	984-329-9225
Fax Number	:

Provider Business Practice Location Address
First Line	:	5015 MILLER DR
Second Line	:
City	:	DURHAM
State	:	NC
Zip	:	27704-1877
Country	:	US
Telephone Number	:	252-822-2834
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2018
Last Update Date	:	04/02/2019

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