Provider Demographics
NPI:1427134907
Name:ROBERTSON, SCOTT ALLEN (DC)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALLEN
Last Name:ROBERTSON
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:PO BOX 613
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:NM
Mailing Address - Zip Code:88065-0613
Mailing Address - Country:US
Mailing Address - Phone:505-538-0000
Mailing Address - Fax:505-538-0000
Practice Address - Street 1:1508 N SWAN ST
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-6534
Practice Address - Country:US
Practice Address - Phone:505-538-0000
Practice Address - Fax:505-538-0000
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMNM1395111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor