Provider Demographics
NPI:1629223151
Name:ROEBUCK, DANIEL COREY (DC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:COREY
Last Name:ROEBUCK
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 1:2725 BIENVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564
Mailing Address - Country:US
Mailing Address - Phone:228-872-7111
Mailing Address - Fax:228-872-4060
Practice Address - Street 1:2725 BIENVILLE BLVD
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-4304
Practice Address - Country:US
Practice Address - Phone:228-872-7111
Practice Address - Fax:228-872-4060
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor