Healthcare Provider Details

I. General information

NPI: 1093912495
Provider Name (Legal Business Name): MARIANAS FOOTCARE CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 CHALAN SAN ANTONIO PMB 1021
TAMUNING GU
96913-3602
US

IV. Provider business mailing address

122 TUN JOSE TOVES WAY
TAMUNING GU
96913
US

V. Phone/Fax

Practice location:
  • Phone: 671-649-3338
  • Fax: 671-649-3336
Mailing address:
  • Phone: 671-649-3338
  • Fax: 671-649-3336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD000005
License Number StateGU

VIII. Authorized Official

Name: DR. TERESA DAMIAN BORJA
Title or Position: DOCTOR
Credential: DPM, BOARD CERTIFIED
Phone: 671-649-3338