Provider Demographics
NPI:1437608874
Name:LAGO, RAFAEL
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:LAGO
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:RAFAEL
Other - Middle Name:
Other - Last Name:LAGO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:201 PLAZA DR # 102
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33936-6071
Mailing Address - Country:US
Mailing Address - Phone:239-491-9329
Mailing Address - Fax:239-491-9359
Practice Address - Street 1:201 PLAZA DR # 102
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6071
Practice Address - Country:US
Practice Address - Phone:239-491-9329
Practice Address - Fax:239-491-9359
Is Sole Proprietor?:No
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9358171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator