Provider Demographics
NPI:1033216825
Name:EVANS, ROBERT M (DC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:M
Last Name:EVANS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-5326
Mailing Address - Country:US
Mailing Address - Phone:304-253-0713
Mailing Address - Fax:304-253-0727
Practice Address - Street 1:403 3RD AVE
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-5326
Practice Address - Country:US
Practice Address - Phone:304-253-0713
Practice Address - Fax:304-253-0727
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV469111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0131329000Medicaid
WVT91531Medicare UPIN
WV0131329000Medicaid