Healthcare Provider Details

I. General information

NPI: 1174637805
Provider Name (Legal Business Name): KEVIN C BORING MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 RESTON PLACE
GASSAWAY WV
26624
US

IV. Provider business mailing address

155 RESTON PLACE
GASSAWAY WV
26624
US

V. Phone/Fax

Practice location:
  • Phone: 304-364-9191
  • Fax: 304-364-9193
Mailing address:
  • Phone: 304-364-9191
  • Fax: 304-364-9193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number001248
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: