Provider Demographics
NPI:1457369159
Name:RAVAGO, RAYMOND JACOB (DC)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JACOB
Last Name:RAVAGO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1123 SOUTHLAKE DR STE F
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29073-7395
Mailing Address - Country:US
Mailing Address - Phone:803-957-0880
Mailing Address - Fax:803-957-0880
Practice Address - Street 1:1123 SOUTHLAKE DR STE F
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-7395
Practice Address - Country:US
Practice Address - Phone:803-957-0880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC2261111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor