Provider Demographics
NPI:1619333648
Name:FLORES, RAFAEL ANGEL JR (SUDC)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:ANGEL
Last Name:FLORES
Suffix:JR
Gender:M
Credentials:SUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1776 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-1951
Mailing Address - Country:US
Mailing Address - Phone:801-910-5892
Mailing Address - Fax:
Practice Address - Street 1:1776 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-1951
Practice Address - Country:US
Practice Address - Phone:801-910-5892
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6955662-6006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)