=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104295658
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAFAEL SIERRA DC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2015
-----------------------------------------------------
Last Update Date | 09/15/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1907 N ANDREWS AVE
-----------------------------------------------------
City | WILTON MANORS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33311-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-567-1924
-----------------------------------------------------
Fax | 954-567-1925
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1907 N ANDREWS AVE
-----------------------------------------------------
City | WILTON MANORS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33311-3914
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-567-1924
-----------------------------------------------------
Fax | 954-567-1925
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH11662
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------