Healthcare Provider Details

I. General information

NPI: 1750382990
Provider Name (Legal Business Name): ANTHONY DALE ROBERTS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W MAIN ST
HAVANA IL
62644-1139
US

IV. Provider business mailing address

303 W MAIN ST
HAVANA IL
62644-1139
US

V. Phone/Fax

Practice location:
  • Phone: 309-543-2629
  • Fax:
Mailing address:
  • Phone: 309-543-2629
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: