Provider Demographics
NPI:1427662725
Name:OTANO, RAFAEL JR (LMT)
Entity type:Individual
Prefix:MR
First Name:RAFAEL JR
Middle Name:
Last Name:OTANO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4445 W 16TH AVE STE 250-A
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33012-7189
Mailing Address - Country:US
Mailing Address - Phone:305-646-8256
Mailing Address - Fax:
Practice Address - Street 1:4445 W 16TH AVE STE 250-A
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-7189
Practice Address - Country:US
Practice Address - Phone:305-646-8256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA66317225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist