Provider Demographics
NPI:1598079873
Name:ROBERTS, NATHAN BRYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:BRYAN
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:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-0124
Mailing Address - Country:US
Mailing Address - Phone:734-845-9064
Mailing Address - Fax:734-557-4000
Practice Address - Street 1:125 W MONROE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1332
Practice Address - Country:US
Practice Address - Phone:269-427-2800
Practice Address - Fax:269-621-2556
Is Sole Proprietor?:No
Enumeration Date:2010-07-29
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINR009713111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1598079873Medicaid