Provider Demographics
NPI:1417286857
Name:BORGSTROM, MICHAEL (LMT)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BORGSTROM
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 NW GLISAN ST
Mailing Address - Street 2:511
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-1163
Mailing Address - Country:US
Mailing Address - Phone:971-570-5829
Mailing Address - Fax:
Practice Address - Street 1:2014 NW GLISAN ST
Practice Address - Street 2:511
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-1163
Practice Address - Country:US
Practice Address - Phone:971-570-5829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-14
Last Update Date:2009-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR9068174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist