MEDICARE: MIKAYLA ROBERTSON DC

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	4532	OK

General Provider Information

NPI Number	:	1790481414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKAYLA ROBERTSON DC

Provider Business Mailing Address
First Line	:	1405 S MAIN ST
Second Line	:
City	:	ELK CITY
State	:	OK
Zip	:	73644-6913
Country	:	US
Telephone Number	:	580-339-8078
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 S MAIN ST
Second Line	:
City	:	ELK CITY
State	:	OK
Zip	:	73644-6913
Country	:	US
Telephone Number	:	580-339-8078
Fax Number	:

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

Provider Enumeration Date	:	02/03/2023
Last Update Date	:	02/03/2023

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