Provider Demographics
NPI:1992374862
Name:RAVELO RIOS, JORGE LAZARO
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:LAZARO
Last Name:RAVELO RIOS
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 1:401 SW 109TH AVE APT 23
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33174-1374
Mailing Address - Country:US
Mailing Address - Phone:786-488-8870
Mailing Address - Fax:
Practice Address - Street 1:401 SW 109TH AVE APT 23
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33174-1374
Practice Address - Country:US
Practice Address - Phone:786-488-8870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician