Provider Demographics
NPI:1114457439
Name:COLBERT, ROY
Entity Type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:COLBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SPRUCE ST STE A
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2410
Mailing Address - Country:US
Mailing Address - Phone:951-715-5050
Mailing Address - Fax:
Practice Address - Street 1:1405 SPRUCE ST STE A
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2410
Practice Address - Country:US
Practice Address - Phone:951-715-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist