Healthcare Provider Details

I. General information

NPI: 1619111812
Provider Name (Legal Business Name): RAFAEL DAVID GARCIA IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2009
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 LIELMANIS AVE HULRBURT FIELD
HURLBURT FIELD FL
32544-5613
US

IV. Provider business mailing address

113 LIELMANIS AVE 1SOSS/OSM HULRBURT FIELD
FORT WALTON BEACH FL
32541
US

V. Phone/Fax

Practice location:
  • Phone: 850-881-5152
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: