Provider Demographics
NPI:1669669800
Name:BORUCKI LARA, KIMBERLY (DC)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:BORUCKI LARA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:LARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:2735 W UNION HILLS DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85027-5033
Mailing Address - Country:US
Mailing Address - Phone:602-973-1630
Mailing Address - Fax:
Practice Address - Street 1:2735 W UNION HILLS DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-5033
Practice Address - Country:US
Practice Address - Phone:602-973-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5427111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZWDBWZ02Medicare PIN
AZU59758Medicare UPIN