Healthcare Provider Details

I. General information

NPI: 1851829618
Provider Name (Legal Business Name): RAPHAEL PATINO ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7815 NW BEACON SQUARE BLVD
BOCA RATON FL
33487-1345
US

IV. Provider business mailing address

1830 N 50TH AVE
HOLLYWOOD FL
33021-4014
US

V. Phone/Fax

Practice location:
  • Phone: 561-241-4903
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberAL4517
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License NumberAL4517
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License NumberAL4517
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2083S0010X
TaxonomySports Medicine (Preventive Medicine) Physician
License NumberAL4517
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberAL4517
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: