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General NPI Number Information
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NPI Number | 1225323629
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Entity Type | Individual
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Provider Name | RAPHAEL BOLANOS
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Gender | Male
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Dates
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Enumeration Date | 06/14/2011
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Last Update Date | 06/14/2011
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Provider Practice Location Address
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Address Line | 315 5TH AVE SUITE 806
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City | NEW YORK
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State | NY
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Zip | 10016-6510
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Country | US
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Telephone | 212-686-8881
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Fax |
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Provider Business Mailing Address
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Address Line | 913 BOULEVARD APARTMENT A
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City | NEW MILFORD
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State | NJ
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Zip | 07646-6416
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 40QA01382600
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License Number State | NJ
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