Provider Demographics
NPI:1184905119
Name:BURFORD, KIMBERLY ELAINE (ABOC)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ELAINE
Last Name:BURFORD
Suffix:
Gender:F
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 FAMOUS AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63139-3043
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6201 FAMOUS AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63139-3043
Practice Address - Country:US
Practice Address - Phone:314-600-1779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-05
Last Update Date:2011-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
015066156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician