Healthcare Provider Details

I. General information

NPI: 1811279458
Provider Name (Legal Business Name): THEA MAE BORDENAVE-SANDE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2011
Last Update Date: 09/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 VAN DAM ST SUITE 12
SARATOGA SPRINGS NY
12866-2023
US

IV. Provider business mailing address

77 VAN DAM ST SUITE 12
SARATOGA SPRINGS NY
12866-2023
US

V. Phone/Fax

Practice location:
  • Phone: 518-587-0801
  • Fax: 518-587-0849
Mailing address:
  • Phone: 518-587-0801
  • Fax: 518-587-0849

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number60-270606
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: