Provider Demographics
NPI:1093104051
Name:WOLTERS, LANDON ROTH (D C)
Entity Type:Individual
Prefix:DR
First Name:LANDON
Middle Name:ROTH
Last Name:WOLTERS
Suffix:
Gender:M
Credentials:D C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 W 4TH ST
Mailing Address - Street 2:P. O. BOX 173
Mailing Address - City:PORTIS
Mailing Address - State:KS
Mailing Address - Zip Code:67474-9260
Mailing Address - Country:US
Mailing Address - Phone:785-346-4749
Mailing Address - Fax:
Practice Address - Street 1:1325 18TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:KS
Practice Address - Zip Code:66935-2280
Practice Address - Country:US
Practice Address - Phone:785-346-4749
Practice Address - Fax:785-346-2249
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-14
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1828111N00000X
KS01-05680111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor