Healthcare Provider Details

I. General information

NPI: 1316542046
Provider Name (Legal Business Name): KEVIN EDWARD BOERINGER SOIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMP LEJUENE
APO AA
28542-0138
US

IV. Provider business mailing address

PSC BOX 20138
APO AA
28542-0138
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7703
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number04208356KB
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: