Provider Demographics
NPI:1285389296
Name:VIDMORE, RASINE AMBER (AAC)
Entity type:Individual
Prefix:
First Name:RASINE
Middle Name:AMBER
Last Name:VIDMORE
Suffix:
Gender:F
Credentials:AAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1813 SUMNER AVE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:WA
Mailing Address - Zip Code:98520-4600
Mailing Address - Country:US
Mailing Address - Phone:360-538-1461
Mailing Address - Fax:360-537-4202
Practice Address - Street 1:1813 SUMNER AVE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4600
Practice Address - Country:US
Practice Address - Phone:360-538-1461
Practice Address - Fax:360-537-4202
Is Sole Proprietor?:No
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator