Provider Demographics
NPI:1558718684
Name:RAFAEL MEDICUS CLINIC, CORP.
Entity Type:Organization
Organization Name:RAFAEL MEDICUS CLINIC, CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GLENN NOEL
Authorized Official - Middle Name:PADILLA
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-474-5141
Mailing Address - Street 1:7424 BRIDGEPORT WAY WEST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-8135
Mailing Address - Country:US
Mailing Address - Phone:253-474-5141
Mailing Address - Fax:253-474-5507
Practice Address - Street 1:7424 BRIDGEPORT WAY WEST
Practice Address - Street 2:SUITE 301
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-8135
Practice Address - Country:US
Practice Address - Phone:253-474-5141
Practice Address - Fax:253-474-5507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00024942207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty