Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 2603 012 | WI |
N | 111NN0400X | Neurology | 2603 012 | WI |
N | 111NS0005X | Chiropractic Sports Physician | 2603 012 | WI |
NPI | 1568572477 |
---|---|
Provider Name | Mr. Glen E Rooyakkers |
First Address | Kimberly, WI 54136 |
Second Address | Kimberly, WI 54136 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/08/2006 |
Last Update Date | 14/07/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38848900 | (05) | WI |
U01810 | (02) |