=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811288145
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VALERIE J. BORSA MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2011
-----------------------------------------------------
Last Update Date | 04/20/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 409 BENEDICTA AVE
-----------------------------------------------------
City | TRINIDAD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81082-2004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-680-2677
-----------------------------------------------------
Fax | 719-846-7895
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1225 E 8TH ST
-----------------------------------------------------
City | TRINIDAD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81082-3159
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-680-2677
-----------------------------------------------------
Fax | 719-846-7895
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. VALERIE J BORSA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 719-680-2677
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | DR38779
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------