Healthcare Provider Details

I. General information

NPI: 1073502134
Provider Name (Legal Business Name): STACEY KIM RAYA DC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 QUEEN ST
SOUTHINGTON CT
06489-1901
US

IV. Provider business mailing address

200 QUEEN ST
SOUTHINGTON CT
06489-1901
US

V. Phone/Fax

Practice location:
  • Phone: 860-621-2225
  • Fax: 860-621-2868
Mailing address:
  • Phone: 860-621-2225
  • Fax: 860-621-2868

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number000938
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: