Provider Demographics
NPI:1760676142
Name:RAIDER, DANIEL (LAC, MAOM)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:
Last Name:RAIDER
Suffix:
Gender:M
Credentials:LAC, MAOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20233 NW SAUVIE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97231-1317
Mailing Address - Country:US
Mailing Address - Phone:503-621-3146
Mailing Address - Fax:
Practice Address - Street 1:2330 NW FLANDERS ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3442
Practice Address - Country:US
Practice Address - Phone:503-701-8766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00624171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist