Provider Demographics
NPI:1366644114
Name:RAEBURN, MICHAEL D (DC, CCSP)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:RAEBURN
Suffix:
Gender:M
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2064 N. KILLLINGSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-4439
Mailing Address - Country:US
Mailing Address - Phone:503-719-7742
Mailing Address - Fax:503-719-7571
Practice Address - Street 1:2064 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4439
Practice Address - Country:US
Practice Address - Phone:503-719-7742
Practice Address - Fax:503-719-7571
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273652111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor