Healthcare Provider Details

I. General information

NPI: 1205228780
Provider Name (Legal Business Name): GAVIN RAVENS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 02/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 WEST AVE APT 1412
MIAMI BEACH FL
33139-6782
US

IV. Provider business mailing address

540 WEST AVE APT 1412
MIAMI BEACH FL
33139-6782
US

V. Phone/Fax

Practice location:
  • Phone: 786-631-0904
  • Fax:
Mailing address:
  • Phone: 786-631-0904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: