Healthcare Provider Details

I. General information

NPI: 1093426215
Provider Name (Legal Business Name): MR. EDGAR LOUIS BORNE III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17270 ROOSEVELT ST
RIVERSIDE CA
92508-9523
US

IV. Provider business mailing address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6596
  • Fax:
Mailing address:
  • Phone: 951-683-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: