Provider Demographics
NPI:1720502677
Name:PENA, RAFAEL DAVID (PTA)
Entity Type:Individual
Prefix:MR
First Name:RAFAEL
Middle Name:DAVID
Last Name:PENA
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 1:2871 POST RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-3116
Mailing Address - Country:US
Mailing Address - Phone:401-463-3060
Mailing Address - Fax:401-732-1045
Practice Address - Street 1:2871 POST RD
Practice Address - Street 2:PREHAB SPORTS MEDICARE SERVICES INC.
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-0076
Practice Address - Country:US
Practice Address - Phone:401-463-3060
Practice Address - Fax:401-732-1045
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPTA01130225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI7542-8OtherBLUE CROSS
RI64-00223OtherUNITED HEALTH
RI402551OtherBLUE CROSS