Basic Information
| Provider Information | |||||||||
| NPI: | 1912364662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RAFFERTY | ||||||||
| FirstName: | RISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1517 | ||||||||
| Address2: | |||||||||
| City: | PENDLETON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 978010410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412784332 | ||||||||
| FaxNumber: | 5412788332 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 COBURG RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414853636 | ||||||||
| FaxNumber: | 5413444305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2016 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LDD10174002 | OR | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 86055261 | 01 | LDD10174002 | OTHER |