Provider Demographics
NPI:1497939276
Name:KEVIN A ROBERTS INC
Entity Type:Organization
Organization Name:KEVIN A ROBERTS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-621-1740
Mailing Address - Street 1:924 24TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:924 24TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2641
Practice Address - Country:US
Practice Address - Phone:801-621-1740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT162481-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870395551005Medicaid
000057676Medicare PIN
UT870395551005Medicaid