Provider Demographics
NPI:1700047040
Name:RAYBURN CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:RAYBURN CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEO
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:RAYBURN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:928-567-1757
Mailing Address - Street 1:PO BOX 1680
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-1680
Mailing Address - Country:US
Mailing Address - Phone:928-567-1757
Mailing Address - Fax:928-567-1722
Practice Address - Street 1:522 W FINNIE FLATS RD
Practice Address - Street 2:SUITE I
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7265
Practice Address - Country:US
Practice Address - Phone:928-567-1757
Practice Address - Fax:928-567-1722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-19
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2005111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ526780739Medicare PIN