Provider Demographics
NPI:1174637805
Name:BORING, KEVIN C (MPT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:C
Last Name:BORING
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 RESTON PLACE
Mailing Address - Street 2:
Mailing Address - City:GASSAWAY
Mailing Address - State:WV
Mailing Address - Zip Code:26624
Mailing Address - Country:US
Mailing Address - Phone:304-364-9191
Mailing Address - Fax:304-364-9193
Practice Address - Street 1:155 RESTON PLACE
Practice Address - Street 2:
Practice Address - City:GASSAWAY
Practice Address - State:WV
Practice Address - Zip Code:26624
Practice Address - Country:US
Practice Address - Phone:304-364-9191
Practice Address - Fax:304-364-9193
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV001248174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0157029000Medicaid
WV204132970OtherTIN