=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922442656
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENJAMIN MICHAEL BORAL D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2013
-----------------------------------------------------
Last Update Date | 08/15/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 740 S LIMESTONE ST K506 KENTUCKY CLINIC
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40536-0284
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-323-9918
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2710 S RIFE MEDICAL LN K506 KENTUCKY CLINIC
-----------------------------------------------------
City | ROGERS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72758-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-338-8000
-----------------------------------------------------
Fax | 479-338-2383
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | E-9631
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------