MEDICARE: MR. RAFAEL DAVID PENA PTA

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	225200000X	Physical Therapy Assistant	PTA01130	RI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7542-8	OTHER	RI	BLUE CROSS
2	64-00223	OTHER	RI	UNITED HEALTH
3	402551	OTHER	RI	BLUE CROSS

General Provider Information

NPI Number	:	1720502677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAFAEL DAVID PENA PTA

Provider Business Mailing Address
First Line	:	2871 POST RD
Second Line	:
City	:	WARWICK
State	:	RI
Zip	:	02886-3116
Country	:	US
Telephone Number	:	401-463-3060
Fax Number	:	401-732-1045

Provider Business Practice Location Address
First Line	:	2871 POST RD
Second Line	:	PREHAB SPORTS MEDICARE SERVICES INC.
City	:	WARWICK
State	:	RI
Zip	:	02886-0076
Country	:	US
Telephone Number	:	401-463-3060
Fax Number	:	401-732-1045

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

Provider Enumeration Date	:	08/02/2017
Last Update Date	:	08/02/2017

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