Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4212 | KY |
N | 111NN1001X | Nutrition | 4212 | KY |
NPI | 1518930742 |
---|---|
Provider Name | Raymond A Roberts |
First Address | Campbellsville, KY 42718-1839 |
Second Address | Campbellsville, KY 42718-1839 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 08/02/2006 |
Last Update Date | 14/04/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
85000073 | (05) | KY |
U43047 | (02) | KY |