Provider Demographics
NPI:1215377643
Name:BORDEN, DYLAN JAMES (MS, ATC)
Entity Type:Individual
Prefix:MR
First Name:DYLAN
Middle Name:JAMES
Last Name:BORDEN
Suffix:
Gender:M
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1288 SPEARS AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-1652
Mailing Address - Country:US
Mailing Address - Phone:503-459-1870
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-1652
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-29
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10004652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR153237OtherATHLETIC TRAINER