Provider Demographics
NPI:1568680429
Name:GOTTENBORG, ROBB J (DC)
Entity Type:Individual
Prefix:
First Name:ROBB
Middle Name:J
Last Name:GOTTENBORG
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 1:817 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:ND
Mailing Address - Zip Code:58341-1521
Mailing Address - Country:US
Mailing Address - Phone:701-324-2262
Mailing Address - Fax:701-324-2299
Practice Address - Street 1:817 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:ND
Practice Address - Zip Code:58341-1521
Practice Address - Country:US
Practice Address - Phone:701-324-2262
Practice Address - Fax:701-324-2299
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND610111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND14699Medicaid
ND14699Medicaid