Provider Demographics
NPI:1730363284
Name:BORGONIA, GERONIMO BALBALEC
Entity type:Individual
Prefix:
First Name:GERONIMO
Middle Name:BALBALEC
Last Name:BORGONIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-195 AUMEA LOOP
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-1208
Mailing Address - Country:US
Mailing Address - Phone:808-277-3808
Mailing Address - Fax:808-625-2425
Practice Address - Street 1:95-195 AUMEA LOOP
Practice Address - Street 2:
Practice Address - City:MILILANI
Practice Address - State:HI
Practice Address - Zip Code:96789-1208
Practice Address - Country:US
Practice Address - Phone:808-277-3808
Practice Address - Fax:808-625-2425
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH00500085343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI59653801Medicaid