Provider Demographics
NPI:1700490737
Name:DR. EDWIN BROOKS ROBERTS LLC
Entity Type:Organization
Organization Name:DR. EDWIN BROOKS ROBERTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:II
Authorized Official - Credentials:DC
Authorized Official - Phone:850-912-8355
Mailing Address - Street 1:3960 W NAVY BLVD STE 17
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-1268
Mailing Address - Country:US
Mailing Address - Phone:850-912-8355
Mailing Address - Fax:850-741-8040
Practice Address - Street 1:3960 W NAVY BLVD STE 17
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-1268
Practice Address - Country:US
Practice Address - Phone:850-912-8355
Practice Address - Fax:850-741-8040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000569800Medicaid