Provider Demographics
NPI:1356336416
Name:BUTLER, ROBERT ALLEN (DC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:BUTLER
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 1:1417 FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:KEWASKUM
Mailing Address - State:WI
Mailing Address - Zip Code:53040-9136
Mailing Address - Country:US
Mailing Address - Phone:262-626-2644
Mailing Address - Fax:262-626-2644
Practice Address - Street 1:1417 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-9136
Practice Address - Country:US
Practice Address - Phone:262-626-2644
Practice Address - Fax:262-626-2644
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2274-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT61613Medicare UPIN
WI75-887Medicare ID - Type Unspecified