Healthcare Provider Details

I. General information

NPI: 1750431284
Provider Name (Legal Business Name): REYMUNDO BORJON JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GATOR BLVD
VIRGINIA BEACH VA
23459-9010
US

IV. Provider business mailing address

PSC 473 BOX 108
YOKOSUKA HONSHU
96349
JP

V. Phone/Fax

Practice location:
  • Phone: 757-462-8088
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: