Provider Demographics
NPI:1679798904
Name:HAVENS, RALPH C (PT, OCS)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:C
Last Name:HAVENS
Suffix:
Gender:M
Credentials:PT, OCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 FORT STOCKTON DR STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1893
Mailing Address - Country:US
Mailing Address - Phone:619-543-1470
Mailing Address - Fax:619-543-1421
Practice Address - Street 1:928 FORT STOCKTON DR STE 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-1893
Practice Address - Country:US
Practice Address - Phone:619-543-1470
Practice Address - Fax:619-543-1421
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT13102225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT13102Medicare ID - Type UnspecifiedPHYSICAL THERAPY