Provider Demographics
NPI:1043323132
Name:ROACH, TODD KENT (DC)
Entity Type:Individual
Prefix:DR
First Name:TODD
Middle Name:KENT
Last Name:ROACH
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 1:756 MALLARD DR
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-1968
Mailing Address - Country:US
Mailing Address - Phone:815-600-1199
Mailing Address - Fax:
Practice Address - Street 1:756 MALLARD DR
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-1968
Practice Address - Country:US
Practice Address - Phone:815-600-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-010254111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL3232026OtherBLUE CROSS BLUE SHIELD
IL211188Medicare ID - Type Unspecified
IL3232026OtherBLUE CROSS BLUE SHIELD