Provider Demographics
NPI:1083796643
Name:HASBROUCK, ROGER CLARENCE (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:CLARENCE
Last Name:HASBROUCK
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 1:915 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-2623
Mailing Address - Country:US
Mailing Address - Phone:920-887-8436
Mailing Address - Fax:920-887-7399
Practice Address - Street 1:915 MADISON ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-2623
Practice Address - Country:US
Practice Address - Phone:920-887-8436
Practice Address - Fax:920-887-7399
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1570111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38764000Medicaid
WI391363647010OtherBLUE CROSS BLUE SHIELD #