Provider Demographics
NPI:1699843656
Name:AMUNDSON, ROGER K (DC)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:K
Last Name:AMUNDSON
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:P.O. BOX 688
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:MT
Mailing Address - Zip Code:59538
Mailing Address - Country:US
Mailing Address - Phone:406-654-1130
Mailing Address - Fax:
Practice Address - Street 1:830 SOUTH CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:MT
Practice Address - Zip Code:59538
Practice Address - Country:US
Practice Address - Phone:406-654-1130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT534111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT534OtherMONTANA LICENSE NUMBER
810502327OtherEIN
MT4256Medicare ID - Type Unspecified
810502327OtherEIN