Provider Demographics
NPI:1952412769
Name:ROBERTS, KEVIN A (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:A
Last Name:ROBERTS
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 1:924 24TH ST STE 2
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-2641
Mailing Address - Country:US
Mailing Address - Phone:801-621-1740
Mailing Address - Fax:801-621-7229
Practice Address - Street 1:924 24TH ST STE 2
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-2641
Practice Address - Country:US
Practice Address - Phone:801-621-1740
Practice Address - Fax:801-621-7229
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT162482-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870395551005Medicaid
UT841630033OtherMAILHANDLERS
UT870395551OtherCHP
UT879470OtherFIRST HEALTH
UT841630033OtherMAILHANDLERS