Provider Demographics
NPI:1225782071
Name:INGRAM, RAPHEAL
Entity Type:Individual
Prefix:
First Name:RAPHEAL
Middle Name:
Last Name:INGRAM
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 1:8727 S KEYSTONE AVE APT 6
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-0730
Mailing Address - Country:US
Mailing Address - Phone:815-216-8310
Mailing Address - Fax:
Practice Address - Street 1:8727 S KEYSTONE AVE APT 6
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0730
Practice Address - Country:US
Practice Address - Phone:815-216-8310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist