MEDICARE: MR. RAPHAEL LUIS VELEZ

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	225700000X	Massage Therapist	0733002406	VA

General Provider Information

NPI Number	:	1891381984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RAPHAEL LUIS VELEZ

Provider Business Mailing Address
First Line	:	3840 CLORE PL
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-7426
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3840 CLORE PL
Second Line	:
City	:	WOODBRIDGE
State	:	VA
Zip	:	22192-7426
Country	:	US
Telephone Number	:	203-410-9530
Fax Number	:

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

Provider Enumeration Date	:	12/14/2020
Last Update Date	:	12/14/2020

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