Provider Demographics
NPI:1942813860
Name:RISAVI, MARY SAKURA (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SAKURA
Last Name:RISAVI
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 UNION RD
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-9114
Mailing Address - Country:US
Mailing Address - Phone:303-905-9723
Mailing Address - Fax:
Practice Address - Street 1:1450 UNION RD
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-9114
Practice Address - Country:US
Practice Address - Phone:303-905-9723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-29
Last Update Date:2020-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18839171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist