Provider Demographics
NPI:1154477669
Name:VAN DEN BERGHE, ROXANNE BETH (DC)
Entity Type:Individual
Prefix:DR
First Name:ROXANNE
Middle Name:BETH
Last Name:VAN DEN BERGHE
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 1:114 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TIPTON
Mailing Address - State:IA
Mailing Address - Zip Code:52772-1728
Mailing Address - Country:US
Mailing Address - Phone:563-886-3636
Mailing Address - Fax:563-886-3555
Practice Address - Street 1:114 W 5TH ST
Practice Address - Street 2:
Practice Address - City:TIPTON
Practice Address - State:IA
Practice Address - Zip Code:52772-1728
Practice Address - Country:US
Practice Address - Phone:563-886-3636
Practice Address - Fax:563-886-3555
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06950111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0747881Medicaid
IAV12194Medicare UPIN
IAI19974Medicare PIN