Provider Demographics
NPI:1700443454
Name:BUROUGH, ANTRESS LAVORIN
Entity Type:Individual
Prefix:
First Name:ANTRESS
Middle Name:LAVORIN
Last Name:BUROUGH
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 1:930 TENNIS WAY
Mailing Address - Street 2:
Mailing Address - City:HAINES CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33844-6726
Mailing Address - Country:US
Mailing Address - Phone:863-332-4666
Mailing Address - Fax:
Practice Address - Street 1:930 TENNIS WAY
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-6726
Practice Address - Country:US
Practice Address - Phone:863-332-4666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care