MEDICARE: RAFAEL MEDICUS CLINIC, CORP.

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	207Q00000X	Family Medicine Physician	MD00024942	WA

General Provider Information

NPI Number	:	1558718684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAFAEL MEDICUS CLINIC, CORP.

Provider Business Mailing Address
First Line	:	7424 BRIDGEPORT WAY WEST
Second Line	:	SUITE 301
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-8135
Country	:	US
Telephone Number	:	253-474-5141
Fax Number	:	253-474-5507

Provider Business Practice Location Address
First Line	:	7424 BRIDGEPORT WAY WEST
Second Line	:	SUITE 301
City	:	LAKEWOOD
State	:	WA
Zip	:	98499-8135
Country	:	US
Telephone Number	:	253-474-5141
Fax Number	:	253-474-5507

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. GLENN NOEL PADILLA RUIZ
Credential	:
Telephone Number	:	253-474-5141

Provider Enumeration Date	:	05/18/2016
Last Update Date	:	05/18/2016

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