Provider Demographics
NPI:1104153089
Name:BO, BOROKA (LAC)
Entity type:Individual
Prefix:
First Name:BOROKA
Middle Name:
Last Name:BO
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 28TH ST
Mailing Address - Street 2:#307
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-1574
Mailing Address - Country:US
Mailing Address - Phone:720-447-7092
Mailing Address - Fax:
Practice Address - Street 1:3545 28TH ST
Practice Address - Street 2:#307
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-1574
Practice Address - Country:US
Practice Address - Phone:720-447-7092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-12
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1479171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist