Provider Demographics
NPI:1699142216
Name:BORREGO, KELLY RAYE (MS, ATC, LAT, CES)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:RAYE
Last Name:BORREGO
Suffix:
Gender:F
Credentials:MS, ATC, LAT, CES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1496 N FAIRVALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-2031
Mailing Address - Country:US
Mailing Address - Phone:626-488-7545
Mailing Address - Fax:
Practice Address - Street 1:440 SAINT KATHERINE DR
Practice Address - Street 2:
Practice Address - City:LA CANADA FLINTRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91011-4113
Practice Address - Country:US
Practice Address - Phone:626-685-8356
Practice Address - Fax:626-685-8503
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT63642255A2300X
CA20000208862255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1699142216OtherATHLETIC TRAINER