Healthcare Provider Details

I. General information

NPI: 1740927656
Provider Name (Legal Business Name): EVAN ROEDER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2022
Last Update Date: 05/13/2022
Certification Date: 05/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8912 BLAKENEY PROFESSIONAL DR STE 100
CHARLOTTE NC
28277-6735
US

IV. Provider business mailing address

222 E BLAND ST UNIT 3
CHARLOTTE NC
28203-6111
US

V. Phone/Fax

Practice location:
  • Phone: 704-544-5353
  • Fax:
Mailing address:
  • Phone: 717-649-3509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number5493
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: