=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194041426
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PHILIP OFIMIANO BORDE JR. IDMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2010
-----------------------------------------------------
Last Update Date | 12/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48TH MDG/RAF LAKENHEATH
-----------------------------------------------------
City | APO
-----------------------------------------------------
State | AA
-----------------------------------------------------
Zip | 09461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-226-8977
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1599 JONES ST 319 OMRS
-----------------------------------------------------
City | GRAND FORKS AFB
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-747-5601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1710I1003X
-----------------------------------------------------
Taxonomy Name | Independent Duty Medical Technicians
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------