Provider Demographics
NPI:1376553248
Name:ROBERTS, LOREN KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:LOREN
Middle Name:KEITH
Last Name:ROBERTS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 GRANT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-3239
Mailing Address - Country:US
Mailing Address - Phone:415-892-0983
Mailing Address - Fax:415-897-4185
Practice Address - Street 1:863 GRANT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-3239
Practice Address - Country:US
Practice Address - Phone:415-892-0983
Practice Address - Fax:415-897-4185
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20766111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NI0900XChiropractic ProvidersChiropractorInternist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0207660Medicare ID - Type Unspecified
CA12101Medicare UPIN