Provider Demographics
NPI:1912364662
Name:RAFFERTY, RISE
Entity Type:Individual
Prefix:
First Name:RISE
Middle Name:
Last Name:RAFFERTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1517
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-0410
Mailing Address - Country:US
Mailing Address - Phone:541-278-4332
Mailing Address - Fax:541-278-8332
Practice Address - Street 1:10 COBURG RD STE 201
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401
Practice Address - Country:US
Practice Address - Phone:541-485-3636
Practice Address - Fax:541-344-4305
Is Sole Proprietor?:No
Enumeration Date:2016-01-26
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLDD10174002133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86055261OtherLDD10174002