Provider Demographics
NPI:1508004482
Name:BORG, ETHAN (MAOM, LAC)
Entity Type:Individual
Prefix:MR
First Name:ETHAN
Middle Name:
Last Name:BORG
Suffix:
Gender:M
Credentials:MAOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 EAST AVE.
Mailing Address - Street 2:SUITE 106A
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14610-1657
Mailing Address - Country:US
Mailing Address - Phone:585-455-2828
Mailing Address - Fax:585-473-0640
Practice Address - Street 1:1501 EAST AVE
Practice Address - Street 2:SUITE 106A
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14610-1657
Practice Address - Country:US
Practice Address - Phone:585-455-2828
Practice Address - Fax:585-473-0640
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-30
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003838171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist