MEDICARE: RAVEN-L INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	AT644	CA
2	225100000X	Physical Therapist	PT 14400	CA

General Provider Information

NPI Number	:	1801175377
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RAVEN-L INC.

Provider Business Mailing Address
First Line	:	1962 MILAN AVE
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-4635
Country	:	US
Telephone Number	:	626-441-3124
Fax Number	:	626-441-3124

Provider Business Practice Location Address
First Line	:	1962 MILAN AVE
Second Line	:
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-4635
Country	:	US
Telephone Number	:	626-441-3124
Fax Number	:	626-441-3124

Authorized Official
Title or Position	:	CFO
Name	:	MRS. JEAN KEIKO RAVENELLE
Credential	:	P.T.
Telephone Number	:	626-441-3124

Provider Enumeration Date	:	08/15/2011
Last Update Date	:	08/15/2011

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Directions to “RAVEN-L INC. ” Practice Location

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