Healthcare Provider Details

I. General information

NPI: 1124237169
Provider Name (Legal Business Name): JUSTIN DEAN BORDER OTR,L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CONCORD ST UNIT A
EL SEGUNDO CA
90245-3741
US

IV. Provider business mailing address

330 CONCORD ST UNIT A
EL SEGUNDO CA
90245-3741
US

V. Phone/Fax

Practice location:
  • Phone: 323-722-8610
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5401
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: