Provider Demographics
NPI:1740307438
Name:MCROBERTS CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:MCROBERTS CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MCROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-848-0058
Mailing Address - Street 1:951 KIMBALL LANE
Mailing Address - Street 2:SUITE 122
Mailing Address - City:VERONA
Mailing Address - State:WI
Mailing Address - Zip Code:53593
Mailing Address - Country:US
Mailing Address - Phone:608-848-0058
Mailing Address - Fax:608-848-0059
Practice Address - Street 1:951 KIMBALL LANE
Practice Address - Street 2:SUITE 122
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593
Practice Address - Country:US
Practice Address - Phone:608-848-0058
Practice Address - Fax:608-848-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3755-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1437116993OtherNPI INDIVIDUAL
WI38934100Medicaid
WI38934100Medicaid
WI1437116993OtherNPI INDIVIDUAL