=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740456540
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PETE BORBOA D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2008
-----------------------------------------------------
Last Update Date | 05/01/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16161 VENTURA BLVD STE 227
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-2884
-----------------------------------------------------
Fax | 818-788-0507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2159 W 20TH ST
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90018-1407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 213-268-7499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Chiropractor
-----------------------------------------------------
License Number | DC29722
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------