Healthcare Provider Details

I. General information

NPI: 1801175377
Provider Name (Legal Business Name): RAVEN-L INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2011
Last Update Date: 08/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1962 MILAN AVE
SOUTH PASADENA CA
91030-4635
US

IV. Provider business mailing address

1962 MILAN AVE
SOUTH PASADENA CA
91030-4635
US

V. Phone/Fax

Practice location:
  • Phone: 626-441-3124
  • Fax: 626-441-3124
Mailing address:
  • Phone: 626-441-3124
  • Fax: 626-441-3124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT 14400
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberAT644
License Number StateCA

VIII. Authorized Official

Name: MRS. JEAN KEIKO RAVENELLE
Title or Position: CFO
Credential: P.T.
Phone: 626-441-3124