Provider Demographics
NPI:1407147200
Name:ROMAN, ROBERT (MAC LAC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:ROMAN
Suffix:
Gender:M
Credentials:MAC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 MAIN ST
Mailing Address - Street 2:P. O. BOX 136
Mailing Address - City:BETHEL
Mailing Address - State:MN
Mailing Address - Zip Code:55005
Mailing Address - Country:US
Mailing Address - Phone:763-269-8051
Mailing Address - Fax:763-269-8051
Practice Address - Street 1:139 MAIN ST
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:MN
Practice Address - Zip Code:55005
Practice Address - Country:US
Practice Address - Phone:763-269-8051
Practice Address - Fax:763-269-8051
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-27
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1482171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN633017700Medicaid
MN246578Medicare PIN