Healthcare Provider Details

I. General information

NPI: 1861420507
Provider Name (Legal Business Name): GLENN BORNE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 COUNTRY CLUB DR
EUNICE LA
70535-6738
US

IV. Provider business mailing address

168 COUNTRY CLUB DR
EUNICE LA
70535-6738
US

V. Phone/Fax

Practice location:
  • Phone: 337-457-8203
  • Fax:
Mailing address:
  • Phone: 337-457-8203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number017646
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: