MEDICARE: GAVIN RAVENS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172M00000X	Mechanotherapist
2	174400000X	Specialist

General Provider Information

NPI Number	:	1205228780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAVIN RAVENS

Provider Business Mailing Address
First Line	:	540 WEST AVE APT 1412
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33139-6782
Country	:	US
Telephone Number	:	786-631-0904
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 WEST AVE APT 1412
Second Line	:
City	:	MIAMI BEACH
State	:	FL
Zip	:	33139-6782
Country	:	US
Telephone Number	:	786-631-0904
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2015
Last Update Date	:	02/20/2015

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