Provider Demographics
NPI:1932108941
Name:OWENS, ROGER WYATT (DC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:WYATT
Last Name:OWENS
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 1:2716 CEDARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-9309
Mailing Address - Country:US
Mailing Address - Phone:573-634-7194
Mailing Address - Fax:
Practice Address - Street 1:3349 AMERICAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-1079
Practice Address - Country:US
Practice Address - Phone:573-635-9655
Practice Address - Fax:573-635-6741
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005470111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000031218Medicare ID - Type Unspecified
MOT71066Medicare UPIN