Provider Demographics
NPI:1982708491
Name:ROLLER, JEFFREY D (DC)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:D
Last Name:ROLLER
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 1:426 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-1313
Mailing Address - Country:US
Mailing Address - Phone:618-635-3200
Mailing Address - Fax:618-635-5445
Practice Address - Street 1:426 W PEARL ST
Practice Address - Street 2:
Practice Address - City:STAUNTON
Practice Address - State:IL
Practice Address - Zip Code:62088-1313
Practice Address - Country:US
Practice Address - Phone:618-635-3200
Practice Address - Fax:618-635-5445
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38-009779111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL210315Medicare ID - Type Unspecified