Healthcare Provider Details

I. General information

NPI: 1922442656
Provider Name (Legal Business Name): BENJAMIN MICHAEL BORAL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2013
Last Update Date: 08/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S LIMESTONE ST K506 KENTUCKY CLINIC
LEXINGTON KY
40536-0284
US

IV. Provider business mailing address

2710 S RIFE MEDICAL LN K506 KENTUCKY CLINIC
ROGERS AR
72758-1452
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9918
  • Fax:
Mailing address:
  • Phone: 479-338-8000
  • Fax: 479-338-2383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-9631
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: