Provider Demographics
NPI:1053986802
Name:MOORE, RAVEN (MSAC)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:MSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 HOGAN ST
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-2128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:147 HARRISON ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1679
Practice Address - Country:US
Practice Address - Phone:708-400-5574
Practice Address - Fax:708-613-9293
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001369171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist