Provider Demographics
NPI:1568572477
Name:ROOYAKKERS, GLEN E (DC DACNB)
Entity Type:Individual
Prefix:MR
First Name:GLEN
Middle Name:E
Last Name:ROOYAKKERS
Suffix:
Gender:M
Credentials:DC DACNB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 EISENHOWER DRIVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:KIMBERLY
Mailing Address - State:WI
Mailing Address - Zip Code:54136
Mailing Address - Country:US
Mailing Address - Phone:920-730-1155
Mailing Address - Fax:920-730-1148
Practice Address - Street 1:702 EISENHOWER DRIVE
Practice Address - Street 2:SUITE G
Practice Address - City:KIMBERLY
Practice Address - State:WI
Practice Address - Zip Code:54136
Practice Address - Country:US
Practice Address - Phone:920-730-1155
Practice Address - Fax:920-730-1148
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2603 012111N00000X, 111NN0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38848900Medicaid
WI38848900Medicaid
WI000170535Medicare ID - Type Unspecified