Provider Demographics
NPI:1437174273
Name:ROBERTS, GORDON LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:LEE
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 1:3494 M-40
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419
Mailing Address - Country:US
Mailing Address - Phone:269-751-2670
Mailing Address - Fax:269-751-2680
Practice Address - Street 1:3494 M-40
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419
Practice Address - Country:US
Practice Address - Phone:269-751-2670
Practice Address - Fax:269-751-2680
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGR004365111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4718950Medicaid
MI4718950Medicaid