Provider Demographics
NPI:1093400707
Name:CARLOS, RAFAEL (DPT)
Entity Type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:CARLOS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1742 S BREEZY MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95834-2683
Mailing Address - Country:US
Mailing Address - Phone:628-235-9743
Mailing Address - Fax:
Practice Address - Street 1:2000 W KETTLEMAN LN STE 106
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-4334
Practice Address - Country:US
Practice Address - Phone:209-207-0849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-07
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY044165225100000X
CA305524225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist