Healthcare Provider Details

I. General information

NPI: 1225805260
Provider Name (Legal Business Name): IAN BORCK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2023
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180B VISTA WAY # 1088
OCEANSIDE CA
92054-5600
US

IV. Provider business mailing address

2180B VISTA WAY # 1088
OCEANSIDE CA
92054-5600
US

V. Phone/Fax

Practice location:
  • Phone: 619-800-3063
  • Fax:
Mailing address:
  • Phone: 619-800-3063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number53143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: