Provider Demographics
NPI:1215933429
Name:WASHBURN, SCOTT OWEN (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:OWEN
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1314
Mailing Address - Street 2:
Mailing Address - City:PORTALES
Mailing Address - State:NM
Mailing Address - Zip Code:88130-1314
Mailing Address - Country:US
Mailing Address - Phone:575-799-0955
Mailing Address - Fax:
Practice Address - Street 1:421 S AVENUE C
Practice Address - Street 2:SUITE C
Practice Address - City:PORTALES
Practice Address - State:NM
Practice Address - Zip Code:88130-6328
Practice Address - Country:US
Practice Address - Phone:575-799-0955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2129111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM350024807OtherRR MC
U26692Medicare UPIN