=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629378757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RABURN FAMILY CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2010
-----------------------------------------------------
Last Update Date | 02/22/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 W MAIN ST
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88210-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-736-3120
-----------------------------------------------------
Fax | 575-736-3122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 W DALLAS AVE
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88210-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-736-3120
-----------------------------------------------------
Fax | 575-736-3122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR/OWNER
-----------------------------------------------------
Name | DR. JUSTIN SHANE RABURN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 575-736-3120
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1874
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------