Healthcare Provider Details

I. General information

NPI: 1265407332
Provider Name (Legal Business Name): DEBORAH IBORG ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 PERSHALL RD
SAINT LOUIS MO
63135-1408
US

IV. Provider business mailing address

14 CHANDLER CT
SAINT CHARLES MO
63303-5340
US

V. Phone/Fax

Practice location:
  • Phone: 314-513-4285
  • Fax:
Mailing address:
  • Phone: 314-513-4285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number00047
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: