Healthcare Provider Details

I. General information

NPI: 1457581092
Provider Name (Legal Business Name): MARK BORREGO OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7100 W 13TH AVE
LAKEWOOD CO
80214-4700
US

IV. Provider business mailing address

7100 W 13TH AVE
LAKEWOOD CO
80214-4700
US

V. Phone/Fax

Practice location:
  • Phone: 303-770-4682
  • Fax: 303-770-4812
Mailing address:
  • Phone: 303-770-4682
  • Fax: 303-770-4812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number1021498
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: