Healthcare Provider Details

I. General information

NPI: 1497799878
Provider Name (Legal Business Name): KEVIN G ROBERTS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 W MAIN ST
FREDERICKTOWN MO
63645-1113
US

IV. Provider business mailing address

PO BOX 189
FREDERICKTOWN MO
63645-0189
US

V. Phone/Fax

Practice location:
  • Phone: 573-783-3188
  • Fax: 573-783-3314
Mailing address:
  • Phone: 573-783-3188
  • Fax: 573-783-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number004431
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: