Provider Demographics
NPI:1932692902
Name:ROTHBAUER, SAMANTHA ROSE (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:ROSE
Last Name:ROTHBAUER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MISS
Other - First Name:SAMANTHA
Other - Middle Name:ROSE
Other - Last Name:KREYER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1865 W WAYZATA BLVD
Mailing Address - Street 2:STE 200
Mailing Address - City:LONG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55356-4100
Mailing Address - Country:US
Mailing Address - Phone:206-623-2225
Mailing Address - Fax:206-686-7246
Practice Address - Street 1:104 PIKE ST STE 210
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2010
Practice Address - Country:US
Practice Address - Phone:206-623-2225
Practice Address - Fax:206-686-7246
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60842943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor