=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831930551
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAOUL TREVERTON LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2024
-----------------------------------------------------
Last Update Date | 06/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9170 JEWEL LAKE RD STE 104
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99502-5390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-310-8101
-----------------------------------------------------
Fax | 907-222-2696
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10337 RIDGE PARK DR
-----------------------------------------------------
City | ANCHORAGE
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99507-7316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-359-0091
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 163973
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------