Healthcare Provider Details

I. General information

NPI: 1033695572
Provider Name (Legal Business Name): NATHAN TYLER BORGET MAED, LAT, ATC, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6632 DIXIE RD
COLUMBUS GA
31905-4218
US

IV. Provider business mailing address

3609 14TH AVE
COLUMBUS GA
31904-7840
US

V. Phone/Fax

Practice location:
  • Phone: 706-545-1788
  • Fax:
Mailing address:
  • Phone: 336-707-6548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003340
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: