Healthcare Provider Details

I. General information

NPI: 1780233213
Provider Name (Legal Business Name): RAFAEL MARTIN PEREZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 09/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 HOOPER AVE APT A
LOS ANGELES CA
90001-1292
US

IV. Provider business mailing address

5955 HOOPER AVE
LOS ANGELES CA
90001-1284
US

V. Phone/Fax

Practice location:
  • Phone: 714-720-1130
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: