Provider Demographics
NPI:1215026356
Name:RAFANAN, MA DAPHANE (LPT)
Entity Type:Individual
Prefix:
First Name:MA DAPHANE
Middle Name:
Last Name:RAFANAN
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E IRVING PARK RD
Mailing Address - Street 2:STE. #107
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172-2048
Mailing Address - Country:US
Mailing Address - Phone:630-439-0009
Mailing Address - Fax:630-439-0011
Practice Address - Street 1:2032 W CERMAK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-4116
Practice Address - Country:US
Practice Address - Phone:773-247-8855
Practice Address - Fax:773-247-8896
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-008728225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232425OtherBC/BS
ILP00073637Medicare ID - Type UnspecifiedRR MEDICARE LOC15
ILK03973Medicare PIN
IDK03972Medicare ID - Type UnspecifiedMEDICARE LOC 15