Provider Demographics
NPI:1396827325
Name:ROESKE, RICHARD ALAN (DC, DABCO, DABCN)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:ALAN
Last Name:ROESKE
Suffix:
Gender:M
Credentials:DC, DABCO, DABCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:757 CONCORD RD. SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2626
Mailing Address - Country:US
Mailing Address - Phone:770-435-0200
Mailing Address - Fax:770-435-4362
Practice Address - Street 1:757 CONCORD RD. SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-2626
Practice Address - Country:US
Practice Address - Phone:770-435-0200
Practice Address - Fax:770-435-4362
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001242111NN0400X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111NN0400XChiropractic ProvidersChiropractorNeurology
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJFPMedicare ID - Type Unspecified
GAU16833Medicare UPIN