Healthcare Provider Details

I. General information

NPI: 1588706774
Provider Name (Legal Business Name): DANIEL MARTIN ROBERTS SA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53028 GLENMOOR ST
ELKHART IN
46514-8923
US

IV. Provider business mailing address

53028 GLENMOOR ST
ELKHART IN
46514-8923
US

V. Phone/Fax

Practice location:
  • Phone: 574-596-9209
  • Fax:
Mailing address:
  • Phone: 574-596-9209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: