Provider Demographics
NPI:1588711766
Name:STACK, ROBERTA ANN (DC)
Entity type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:ANN
Last Name:STACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 WESTON ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WALTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02453-7756
Mailing Address - Country:US
Mailing Address - Phone:781-891-1722
Mailing Address - Fax:
Practice Address - Street 1:42 WESTON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-7756
Practice Address - Country:US
Practice Address - Phone:781-891-1722
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACH 706111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY35525OtherBCBSMA
MAY35525Medicare ID - Type Unspecified