Provider Demographics
NPI:1518930742
Name:ROBERTS, RAYMOND A (DC)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
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 1:108 LEBANON AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-1839
Mailing Address - Country:US
Mailing Address - Phone:270-789-0060
Mailing Address - Fax:270-465-0307
Practice Address - Street 1:108 LEBANON AVE
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-1839
Practice Address - Country:US
Practice Address - Phone:270-789-0060
Practice Address - Fax:270-465-0307
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4212111N00000X, 111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85000073Medicaid
KY6066001Medicare ID - Type Unspecified
KY85000073Medicaid