Healthcare Provider Details

I. General information

NPI: 1730363284
Provider Name (Legal Business Name): GERONIMO BALBALEC BORGONIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95-195 AUMEA LOOP
MILILANI HI
96789-1208
US

IV. Provider business mailing address

95-195 AUMEA LOOP
MILILANI HI
96789-1208
US

V. Phone/Fax

Practice location:
  • Phone: 808-277-3808
  • Fax: 808-625-2425
Mailing address:
  • Phone: 808-277-3808
  • Fax: 808-625-2425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberH00500085
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: