Provider Demographics
NPI:1396915229
Name:BORAL, PERCIVAL GIMENEZ (IDC)
Entity type:Individual
Prefix:MR
First Name:PERCIVAL
Middle Name:GIMENEZ
Last Name:BORAL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:739 KIRKWALL DR
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-8137
Mailing Address - Country:US
Mailing Address - Phone:626-241-8335
Mailing Address - Fax:
Practice Address - Street 1:1ST MLG VANDERGRIFT RD
Practice Address - Street 2:
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5019
Practice Address - Country:US
Practice Address - Phone:760-763-0760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman