Provider Demographics
NPI:1104018373
Name:ROTH FAMILY CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:ROTH FAMILY CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-233-2517
Mailing Address - Street 1:1906 30TH AVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560
Mailing Address - Country:US
Mailing Address - Phone:218-233-2517
Mailing Address - Fax:218-233-6737
Practice Address - Street 1:1906 30TH AVE SOUTH
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:218-233-2517
Practice Address - Fax:218-233-6737
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2016-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3113111N00000X
MN3114111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC02154Medicare PIN