Provider Demographics
NPI:1225094915
Name:POORTVLIET, ROBYNN MICHELLE (DC)
Entity Type:Individual
Prefix:
First Name:ROBYNN
Middle Name:MICHELLE
Last Name:POORTVLIET
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MRS
Other - First Name:ROBYNN
Other - Middle Name:MICHELLE
Other - Last Name:ROGGENBUCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:1116 NW BELL AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507
Mailing Address - Country:US
Mailing Address - Phone:580-353-1519
Mailing Address - Fax:580-353-1519
Practice Address - Street 1:8901 S SANTE FE
Practice Address - Street 2:SUITE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73139
Practice Address - Country:US
Practice Address - Phone:405-634-0042
Practice Address - Fax:405-632-7976
Is Sole Proprietor?:No
Enumeration Date:2006-04-22
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3446111N00000X
TX8112111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK248305602Medicare PIN