Provider Demographics
NPI:1649282096
Name:HARGRAVE, SHILO (LAC)
Entity type:Individual
Prefix:
First Name:SHILO
Middle Name:
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 KUTTER RD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3169
Mailing Address - Country:US
Mailing Address - Phone:907-374-8889
Mailing Address - Fax:907-452-3695
Practice Address - Street 1:104 KUTTER RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3169
Practice Address - Country:US
Practice Address - Phone:907-374-8889
Practice Address - Fax:907-452-3695
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist