Provider Demographics
NPI:1730912692
Name:MOGAN, RAYDENE
Entity type:Individual
Prefix:
First Name:RAYDENE
Middle Name:
Last Name:MOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1332 23RD ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-5521
Mailing Address - Country:US
Mailing Address - Phone:810-824-4341
Mailing Address - Fax:
Practice Address - Street 1:2223 7TH ST APT 1
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-6446
Practice Address - Country:US
Practice Address - Phone:810-292-9274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-24
Last Update Date:2024-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide