Provider Demographics
NPI:1184125502
Name:BORGILT, RAVEN MICHALA (LMT)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:MICHALA
Last Name:BORGILT
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 1:2941 ANDERSON CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TALENT
Mailing Address - State:OR
Mailing Address - Zip Code:97540
Mailing Address - Country:US
Mailing Address - Phone:541-601-7634
Mailing Address - Fax:
Practice Address - Street 1:3550 NATIONAL DRIVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-324-4179
Practice Address - Fax:541-500-1818
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023504225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist