Provider Demographics
NPI:1508300781
Name:VANBUREN, TYRONE (LMT)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:VANBUREN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 PAILET AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-3621
Mailing Address - Country:US
Mailing Address - Phone:504-214-9103
Mailing Address - Fax:
Practice Address - Street 1:3701 CANAL STREET
Practice Address - Street 2:SUITE 129
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6158
Practice Address - Country:US
Practice Address - Phone:504-355-1621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA8387225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist