Provider Demographics
NPI:1962970061
Name:BORREGO, DONALD (COTA/L)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:
Last Name:BORREGO
Suffix:
Gender:M
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 COPPER AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-1473
Mailing Address - Country:US
Mailing Address - Phone:505-266-5557
Mailing Address - Fax:
Practice Address - Street 1:5200 COPPER NE
Practice Address - Street 2:#7
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-266-5557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3302224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM$$$$$$$$$Medicaid