Provider Demographics
NPI:1104400670
Name:CORPORAN, RAFAEL A (LMT)
Entity Type:Individual
Prefix:MRS
First Name:RAFAEL
Middle Name:A
Last Name:CORPORAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 SW 38TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33134-7348
Mailing Address - Country:US
Mailing Address - Phone:214-434-5050
Mailing Address - Fax:
Practice Address - Street 1:2800 SW 38TH CT
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33134-7348
Practice Address - Country:US
Practice Address - Phone:214-434-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-10
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA72217225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist