Provider Demographics
NPI:1396964250
Name:BOUTWELL, ROGER BERT (DC)
Entity type:Individual
Prefix:DR
First Name:ROGER
Middle Name:BERT
Last Name:BOUTWELL
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 1:3434 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907
Mailing Address - Country:US
Mailing Address - Phone:706-569-6996
Mailing Address - Fax:706-569-8898
Practice Address - Street 1:3434 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907
Practice Address - Country:US
Practice Address - Phone:706-569-6996
Practice Address - Fax:706-569-8898
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01984111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor