=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629225784
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STRAIGHT CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2008
-----------------------------------------------------
Last Update Date | 09/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 SOUTHERN BLVD SE STE 304
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-2087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-891-2280
-----------------------------------------------------
Fax | 505-891-2285
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3301 SOUTHERN BLVD SE STE 304
-----------------------------------------------------
City | RIO RANCHO
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87124-2087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-891-2280
-----------------------------------------------------
Fax | 505-891-2285
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRAD FACKRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 505-891-2280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1577
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------