Provider Demographics
NPI:1629595541
Name:BURFORD, MARY ILLONA
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ILLONA
Last Name:BURFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1324
Mailing Address - Street 2:
Mailing Address - City:PALMER LAKE
Mailing Address - State:CO
Mailing Address - Zip Code:80133-1324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 PARK ST
Practice Address - Street 2:
Practice Address - City:PALMER LAKE
Practice Address - State:CO
Practice Address - Zip Code:80133
Practice Address - Country:US
Practice Address - Phone:719-651-7635
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care