1780641530 NPI number — MRS. ALICIA R BORST P.A.C.

Table of content: MRS. ALICIA R BORST P.A.C. (NPI 1780641530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780641530 NPI number — MRS. ALICIA R BORST P.A.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BORST
Provider First Name:
ALICIA
Provider Middle Name:
R
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.C.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREGG
Provider Other First Name:
ALICIA
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
P.A.C.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780641530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3960 W. WAINWRIGHT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-384-9023
Provider Business Mailing Address Fax Number:
208-388-1683

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3960 W. WAINWRIGHT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-384-9023
Provider Business Practice Location Address Fax Number:
208-388-1683
Provider Enumeration Date:
04/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AS0400X , with the licence number:  787 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0078PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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