Healthcare Provider Details

I. General information

NPI: 1750826467
Provider Name (Legal Business Name): JONAH BORNE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2017
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E 5TH ST
EDGARD LA
70049-2354
US

IV. Provider business mailing address

300 E 5TH ST
EDGARD LA
70049-2354
US

V. Phone/Fax

Practice location:
  • Phone: 985-210-7233
  • Fax:
Mailing address:
  • Phone: 985-210-7233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: