Healthcare Provider Details

I. General information

NPI: 1629225784
Provider Name (Legal Business Name): STRAIGHT CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 SOUTHERN BLVD SE STE 304
RIO RANCHO NM
87124-2087
US

IV. Provider business mailing address

3301 SOUTHERN BLVD SE STE 304
RIO RANCHO NM
87124-2087
US

V. Phone/Fax

Practice location:
  • Phone: 505-891-2280
  • Fax: 505-891-2285
Mailing address:
  • Phone: 505-891-2280
  • Fax: 505-891-2285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1577
License Number StateNM

VIII. Authorized Official

Name: BRAD FACKRELL
Title or Position: OWNER
Credential:
Phone: 505-891-2280