Provider Demographics
NPI:1548763352
Name:RAVEN ACUPUNCTURE PLLC
Entity Type:Organization
Organization Name:RAVEN ACUPUNCTURE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURIST
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:303-912-5401
Mailing Address - Street 1:36824 SE SUNSET VIEW RD
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-6769
Mailing Address - Country:US
Mailing Address - Phone:303-912-5401
Mailing Address - Fax:
Practice Address - Street 1:120 NE 117TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-5020
Practice Address - Country:US
Practice Address - Phone:503-987-0574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-18
Last Update Date:2018-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60807373171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500679284Medicaid