Provider Demographics
NPI:1255448734
Name:BORNE, SIDNEY
Entity type:Individual
Prefix:
First Name:SIDNEY
Middle Name:
Last Name:BORNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1190 WAGUESPACK ST
Mailing Address - Street 2:
Mailing Address - City:VACHERIE
Mailing Address - State:LA
Mailing Address - Zip Code:70090-5300
Mailing Address - Country:US
Mailing Address - Phone:504-818-1173
Mailing Address - Fax:
Practice Address - Street 1:2132 GAUSE BLVD E
Practice Address - Street 2:STE 6
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70461-4243
Practice Address - Country:US
Practice Address - Phone:985-646-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA05171OtherLICENSE #