Provider Demographics
NPI:1669876066
Name:BURCH, KEVIN SR
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:BURCH
Suffix:SR
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 1:6103 MAGNOLIA POINTE BLVD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-9059
Mailing Address - Country:US
Mailing Address - Phone:386-898-3942
Mailing Address - Fax:
Practice Address - Street 1:1670 CLAIRMONT RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30033-4004
Practice Address - Country:US
Practice Address - Phone:404-321-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0014190811376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide