Provider Demographics
NPI:1083121917
Name:ROARK, BRENT ALEXANDER (ATC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ALEXANDER
Last Name:ROARK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 VERMILLION ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:WV
Mailing Address - Zip Code:24712-9027
Mailing Address - Country:US
Mailing Address - Phone:304-384-6320
Mailing Address - Fax:304-384-5117
Practice Address - Street 1:1000 VERMILLION ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:WV
Practice Address - Zip Code:24712-9027
Practice Address - Country:US
Practice Address - Phone:304-384-6320
Practice Address - Fax:304-384-5117
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-31
Last Update Date:2017-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAT0013702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer