Provider Demographics
NPI:1194156489
Name:AVECILLAS, RAFAEL
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:AVECILLAS
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 1:2644 FRITZKE RD
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:FL
Mailing Address - Zip Code:33527-3433
Mailing Address - Country:US
Mailing Address - Phone:813-325-9450
Mailing Address - Fax:
Practice Address - Street 1:2644 FRITZKE RD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-3433
Practice Address - Country:US
Practice Address - Phone:813-325-9450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL11922310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility