Provider Demographics
NPI:1114364254
Name:FORESTIERI, RAPHAEL FREDRICK (LAC)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:FREDRICK
Last Name:FORESTIERI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2307 FOREST PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3618
Mailing Address - Country:US
Mailing Address - Phone:260-797-1223
Mailing Address - Fax:
Practice Address - Street 1:487 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-2051
Practice Address - Country:US
Practice Address - Phone:260-637-6757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-30
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN84000156A171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist