Provider Demographics
NPI:1407248081
Name:BORAH, ANDREW S (ATC)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:S
Last Name:BORAH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 MEADOW VALE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-4929
Mailing Address - Country:US
Mailing Address - Phone:802-318-2717
Mailing Address - Fax:
Practice Address - Street 1:1764 MEADOW VALE DR
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-4929
Practice Address - Country:US
Practice Address - Phone:802-318-2717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2000008263OtherBOC