1114364254 NPI number — RAPHAEL FREDRICK FORESTIERI L.AC.

Table of content: RAPHAEL FREDRICK FORESTIERI L.AC. (NPI 1114364254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114364254 NPI number — RAPHAEL FREDRICK FORESTIERI L.AC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORESTIERI
Provider First Name:
RAPHAEL
Provider Middle Name:
FREDRICK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
L.AC.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114364254
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2307 FOREST PARK BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46805-3618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-797-1223
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
487 E DUPONT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46825-2051
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-637-6757
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  84000156A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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