Provider Demographics
NPI:1376034348
Name:BURSTON, EDDIE REGINALD II
Entity Type:Individual
Prefix:MR
First Name:EDDIE
Middle Name:REGINALD
Last Name:BURSTON
Suffix:II
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 1:19612 VILLA CT EHS7
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076
Mailing Address - Country:US
Mailing Address - Phone:858-265-9992
Mailing Address - Fax:858-798-5221
Practice Address - Street 1:12727 CAMINO EMPARRADO
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128
Practice Address - Country:US
Practice Address - Phone:858-265-9992
Practice Address - Fax:858-798-5221
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIB8163X253Z00000X
CA7516084757253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care