Healthcare Provider Details

I. General information

NPI: 1649282096
Provider Name (Legal Business Name): SHILO HARGRAVE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 KUTTER RD
FAIRBANKS AK
99701-3169
US

IV. Provider business mailing address

104 KUTTER RD
FAIRBANKS AK
99701-3169
US

V. Phone/Fax

Practice location:
  • Phone: 907-374-8889
  • Fax: 907-452-3695
Mailing address:
  • Phone: 907-374-8889
  • Fax: 907-452-3695

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number100
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: