Provider Demographics
NPI:1942615109
Name:BORDES, JUAN CARLOS (OTR/L)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLOS
Last Name:BORDES
Suffix:
Gender:M
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10777 POPLAR ST
Mailing Address - Street 2:APT. 207
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2245
Mailing Address - Country:US
Mailing Address - Phone:909-446-2761
Mailing Address - Fax:
Practice Address - Street 1:10777 POPLAR ST APT 207
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2249
Practice Address - Country:US
Practice Address - Phone:909-446-2761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14426225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist