MEDICARE: MADISON KAY ROBERTS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2020002621	MO

General Provider Information

NPI Number	:	1588294920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON KAY ROBERTS

Provider Business Mailing Address
First Line	:	331 BRIGHTSAND CT
Second Line	:
City	:	MANCHESTER
State	:	MO
Zip	:	63011-3901
Country	:	US
Telephone Number	:	515-771-8873
Fax Number	:

Provider Business Practice Location Address
First Line	:	1809 HERITAGE HILLS DR
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-4624
Country	:	US
Telephone Number	:	515-771-8873
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2020
Last Update Date	:	01/24/2020

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