Provider Demographics
NPI:1891138665
Name:RAZLOGA, RAISA MICHYLOVNA (LMT)
Entity Type:Individual
Prefix:
First Name:RAISA
Middle Name:MICHYLOVNA
Last Name:RAZLOGA
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5206 EDGECREST CT SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1840
Mailing Address - Country:US
Mailing Address - Phone:503-856-5166
Mailing Address - Fax:503-581-6102
Practice Address - Street 1:3530 LIBERTY RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-5622
Practice Address - Country:US
Practice Address - Phone:503-856-5166
Practice Address - Fax:503-581-6102
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR12184172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker