Provider Demographics
NPI:1588428205
Name:ROBERTSON, ROBERT CLINTON
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:CLINTON
Last Name:ROBERTSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3370 RIGHT FORK BIG LYNN CREEK RD.
Mailing Address - Street 2:
Mailing Address - City:EAST LYNN
Mailing Address - State:WV
Mailing Address - Zip Code:25517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3370 RIGHT FORK BIG LYNN CREEK RD.
Practice Address - Street 2:
Practice Address - City:EAST LYNN
Practice Address - State:WV
Practice Address - Zip Code:25517
Practice Address - Country:US
Practice Address - Phone:304-733-1094
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant