Provider Demographics
NPI:1710248497
Name:ROESENER, COLTON WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:COLTON
Middle Name:WADE
Last Name:ROESENER
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 428
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:CO
Mailing Address - Zip Code:81639-0428
Mailing Address - Country:US
Mailing Address - Phone:970-276-1215
Mailing Address - Fax:970-276-1216
Practice Address - Street 1:153 WEST JEFFERSON AVENUE
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:CO
Practice Address - Zip Code:81639-0428
Practice Address - Country:US
Practice Address - Phone:970-276-1215
Practice Address - Fax:970-276-1216
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-30
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6870111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor