Healthcare Provider Details

I. General information

NPI: 1194041426
Provider Name (Legal Business Name): PHILIP OFIMIANO BORDE JR. IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MDG/RAF LAKENHEATH
APO AA
09461
US

IV. Provider business mailing address

1599 JONES ST 319 OMRS
GRAND FORKS AFB ND
58205
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8977
  • Fax:
Mailing address:
  • Phone: 701-747-5601
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: