Provider Demographics
NPI:1033316419
Name:BRENT A ROTH DC INC
Entity Type:Organization
Organization Name:BRENT A ROTH DC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-542-8247
Mailing Address - Street 1:501 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43526-1083
Mailing Address - Country:US
Mailing Address - Phone:419-542-8247
Mailing Address - Fax:419-542-6716
Practice Address - Street 1:501 W HIGH ST
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43526-1083
Practice Address - Country:US
Practice Address - Phone:419-542-8247
Practice Address - Fax:419-542-6726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH719111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHBR9261941Medicare ID - Type Unspecified
OHT46990Medicare UPIN