Provider Demographics
NPI:1972625721
Name:DR. RAFAEL O. MOLLEGA , JR. OF NORTHWEST FLORIDA, INC
Entity type:Organization
Organization Name:DR. RAFAEL O. MOLLEGA , JR. OF NORTHWEST FLORIDA, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER/INSURANCE PERSONNEL
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-269-3937
Mailing Address - Street 1:12671 US HWY 98 W
Mailing Address - Street 2:STE 216
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32550
Mailing Address - Country:US
Mailing Address - Phone:850-269-3937
Mailing Address - Fax:850-269-1988
Practice Address - Street 1:12671 US HWY 98 W
Practice Address - Street 2:STE 216
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32550
Practice Address - Country:US
Practice Address - Phone:850-269-3937
Practice Address - Fax:850-269-1988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2010-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLCG923AMedicare PIN
FL3924230001Medicare NSC