Provider Demographics
NPI:1629225784
Name:STRAIGHT CHIROPRACTIC
Entity Type:Organization
Organization Name:STRAIGHT CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FACKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-891-2280
Mailing Address - Street 1:3301 SOUTHERN BLVD SE STE 304
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2087
Mailing Address - Country:US
Mailing Address - Phone:505-891-2280
Mailing Address - Fax:505-891-2285
Practice Address - Street 1:3301 SOUTHERN BLVD SE STE 304
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-2087
Practice Address - Country:US
Practice Address - Phone:505-891-2280
Practice Address - Fax:505-891-2285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM300521050Medicare PIN