Provider Demographics
NPI:1477365856
Name:MICA RAE, LLC.
Entity type:Organization
Organization Name:MICA RAE, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOEHNER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:302-212-7994
Mailing Address - Street 1:705 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:DELMAR
Mailing Address - State:DE
Mailing Address - Zip Code:19940-1347
Mailing Address - Country:US
Mailing Address - Phone:302-212-7994
Mailing Address - Fax:866-635-3408
Practice Address - Street 1:705 E STATE ST
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:DE
Practice Address - Zip Code:19940-1347
Practice Address - Country:US
Practice Address - Phone:302-212-7994
Practice Address - Fax:866-635-3408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care