Provider Demographics
NPI:1194456608
Name:BOUMAILA, RAPHAEL (MASSAGE THERAPIST)
Entity Type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:
Last Name:BOUMAILA
Suffix:
Gender:M
Credentials:MASSAGE THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37938 ABRAHAM ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-3834
Mailing Address - Country:US
Mailing Address - Phone:917-952-9313
Mailing Address - Fax:
Practice Address - Street 1:37938 ABRAHAM ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-3834
Practice Address - Country:US
Practice Address - Phone:917-952-9313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA90527225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist