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General NPI Number Information
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NPI Number | 1699142216
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Entity Type | Individual
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Provider Name | KELLY RAYE BORREGO MS, ATC, LAT, CES
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Gender | Female
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Dates
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Enumeration Date | 08/31/2015
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Last Update Date | 09/24/2018
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Provider Practice Location Address
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Address Line | 440 SAINT KATHERINE DR
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City | LA CANADA FLINTRIDGE
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State | CA
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Zip | 91011-4113
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Country | US
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Telephone | 626-685-8356
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Fax | 626-685-8503
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Provider Business Mailing Address
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Address Line | 1496 N FAIRVALLEY AVE
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City | COVINA
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State | CA
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Zip | 91722-2031
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Country | US
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Telephone | 626-488-7545
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | AT6364
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 2000020886
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License Number State | CA
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