Provider Demographics
NPI:1083624720
Name:KNUDSEN, ROBERTA ELIZABETH (DC)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:ELIZABETH
Last Name:KNUDSEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3675 N 129TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-5211
Mailing Address - Country:US
Mailing Address - Phone:402-493-6800
Mailing Address - Fax:402-614-1635
Practice Address - Street 1:3675 N 129TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-5211
Practice Address - Country:US
Practice Address - Phone:402-493-6800
Practice Address - Fax:402-614-1635
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-08
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1207111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025328800Medicaid
NE279171Medicare ID - Type Unspecified
NE10025328800Medicaid