Provider Demographics
NPI:1396304127
Name:PEREZ, RAFAEL EDUARDO (PTA)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:EDUARDO
Last Name:PEREZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 N VICTORIA PARK RD APT 1
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-2452
Mailing Address - Country:US
Mailing Address - Phone:708-415-6419
Mailing Address - Fax:
Practice Address - Street 1:6061 PALMETTO CIR N
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3602
Practice Address - Country:US
Practice Address - Phone:866-652-4437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-05
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA28954225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant