1114496551 NPI number — RAPHAEL SANTOS BOCOBO RBT

Table of content: RAPHAEL SANTOS BOCOBO RBT (NPI 1114496551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114496551 NPI number — RAPHAEL SANTOS BOCOBO RBT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOCOBO
Provider First Name:
RAPHAEL
Provider Middle Name:
SANTOS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RBT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114496551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1324 ENCHANTED WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN MATEO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94402-3620
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-576-4849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
36 OAK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN VIEW
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94040-2629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-938-3600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106S00000X , with the licence number:  18-68631 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)