Provider Demographics
NPI:1477641850
Name:ROBERTSON, KEITH S (DC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:S
Last Name:ROBERTSON
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 1:16169 HESPERIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LORENZO
Mailing Address - State:CA
Mailing Address - Zip Code:94580-2451
Mailing Address - Country:US
Mailing Address - Phone:510-276-7696
Mailing Address - Fax:510-276-7695
Practice Address - Street 1:16169 HESPERIAN BLVD
Practice Address - Street 2:
Practice Address - City:SAN LORENZO
Practice Address - State:CA
Practice Address - Zip Code:94580-2451
Practice Address - Country:US
Practice Address - Phone:510-276-7696
Practice Address - Fax:510-276-7695
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23099111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC023099OtherMEDICAL LISCENSE NUMBER
CADC023099OtherMEDICAL LISCENSE NUMBER
CADC0230990Medicare UPIN