Provider Demographics
NPI:1144954231
Name:BASMAYOR-BURROWS, EVA REGINALDO
Entity type:Individual
Prefix:MRS
First Name:EVA
Middle Name:REGINALDO
Last Name:BASMAYOR-BURROWS
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 1:17653 HIAWATHA DR
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9405
Mailing Address - Country:US
Mailing Address - Phone:616-502-6806
Mailing Address - Fax:
Practice Address - Street 1:17653 HIAWATHA DR
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9405
Practice Address - Country:US
Practice Address - Phone:616-502-6806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF00309513253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency