Provider Demographics
NPI:1275703027
Name:ROBERTS, EDWIN BROOKS (D C)
Entity Type:Individual
Prefix:DR
First Name:EDWIN
Middle Name:BROOKS
Last Name:ROBERTS
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 1:3960 W NAVY BLVD STE 17
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-1268
Mailing Address - Country:US
Mailing Address - Phone:850-912-8355
Mailing Address - Fax:850-741-8040
Practice Address - Street 1:3960 W NAVY BLVD STE 17
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-1268
Practice Address - Country:US
Practice Address - Phone:850-912-8355
Practice Address - Fax:850-741-8040
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-07
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9526111NR0400X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAQ706ZOtherMEDICARE PTAN