Provider Demographics
NPI:1447716980
Name:BORNHORST, DEREK PAUL
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:PAUL
Last Name:BORNHORST
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 1:2203 MARCHBANKS AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-2247
Mailing Address - Country:US
Mailing Address - Phone:937-726-7324
Mailing Address - Fax:
Practice Address - Street 1:2203 MARCHBANKS AVE
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2247
Practice Address - Country:US
Practice Address - Phone:937-726-7324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-20
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11102225100000X
OHPT016629261QP2000X
KY007331261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy