Basic Information
| Provider Information | |||||||||
| NPI: | 1366749095 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RAPHA CLINICS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 N 185TH ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | SHORELINE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981334011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065421000 | ||||||||
| FaxNumber: | 2065425353 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 N 185TH ST STE 202 | ||||||||
| Address2: | |||||||||
| City: | SHORELINE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981334011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065421000 | ||||||||
| FaxNumber: | 2065425353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2011 | ||||||||
| LastUpdateDate: | 02/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | JOO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | Y | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2065421000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | PO00000700 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine | 213ES0103X | PO00000700 | WA | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | PO00000700 | WA | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | GAB36982 | 01 | WA | MEDICARE PTAN | OTHER | GAB36984 | 01 | WA | MEDICARE PTAN | OTHER | 115773 | 05 | WA | MEDICAID | GAB36981 | 01 | MEDICARE PTAN | OTHER | GAB36983 | 01 | WA | MEDICARE PTAN | OTHER |