Provider Demographics
NPI:1083385199
Name:OGBURN, ANDREW
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:OGBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 GLEN MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-5635
Mailing Address - Country:US
Mailing Address - Phone:847-721-5574
Mailing Address - Fax:
Practice Address - Street 1:11 GLEN MEADOW DR
Practice Address - Street 2:
Practice Address - City:ANGIER
Practice Address - State:NC
Practice Address - Zip Code:27501-5635
Practice Address - Country:US
Practice Address - Phone:847-721-5574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17655225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty