Provider Demographics
NPI:1205228780
Name:RAVENS, GAVIN
Entity Type:Individual
Prefix:
First Name:GAVIN
Middle Name:
Last Name:RAVENS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:540 WEST AVE APT 1412
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-6782
Mailing Address - Country:US
Mailing Address - Phone:786-631-0904
Mailing Address - Fax:
Practice Address - Street 1:540 WEST AVE APT 1412
Practice Address - Street 2:
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-6782
Practice Address - Country:US
Practice Address - Phone:786-631-0904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No172M00000XOther Service ProvidersMechanotherapist