Provider Demographics
NPI:1174542591
Name:RAY, FAWN C (DC)
Entity type:Individual
Prefix:DR
First Name:FAWN
Middle Name:C
Last Name:RAY
Suffix:
Gender:F
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 452
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-0452
Mailing Address - Country:US
Mailing Address - Phone:817-991-1997
Mailing Address - Fax:
Practice Address - Street 1:5004 THOMPSON TER STE 102
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6130
Practice Address - Country:US
Practice Address - Phone:817-991-1997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1806111N00000X
TX11962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10810525OtherCIGNA
TN7329276OtherAETNA
TN4028070OtherBCBS
TN10810525OtherCIGNA
TN3971991Medicare ID - Type Unspecified