Provider Demographics
NPI:1497311401
Name:BORDEN, ROSA L
Entity Type:Individual
Prefix:
First Name:ROSA
Middle Name:L
Last Name:BORDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:GA
Mailing Address - Zip Code:31092-1529
Mailing Address - Country:US
Mailing Address - Phone:478-244-4351
Mailing Address - Fax:
Practice Address - Street 1:607 S 5TH ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:GA
Practice Address - Zip Code:31092-1529
Practice Address - Country:US
Practice Address - Phone:478-244-4351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051413705171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor