=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093832305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAFAEL CALES III PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 STACK BLVD
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-8500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-676-9011
-----------------------------------------------------
Fax | 321-676-9011
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 503 MELANIE CIR
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-8427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-837-1953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | PTA19701
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------