MEDICARE: MR. CARL EDISON BORDERS III CCC-SLP/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SP11420	CA

General Provider Information

NPI Number	:	1770719478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL EDISON BORDERS III CCC-SLP/L

Provider Business Mailing Address
First Line	:	1724 SPEYER LN
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-4730
Country	:	US
Telephone Number	:	310-971-7416
Fax Number	:

Provider Business Practice Location Address
First Line	:	1724 SPEYER LN
Second Line	:
City	:	REDONDO BEACH
State	:	CA
Zip	:	90278-4730
Country	:	US
Telephone Number	:	310-971-7416
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2009
Last Update Date	:	06/08/2009

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