Provider Demographics
NPI:1114175551
Name:ROTH, MICHAEL (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:ROTH
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 1:1787 MESA VERDE AVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-6531
Mailing Address - Country:US
Mailing Address - Phone:805-644-0461
Mailing Address - Fax:805-644-1501
Practice Address - Street 1:1787 MESA VERDE AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-6531
Practice Address - Country:US
Practice Address - Phone:805-644-0461
Practice Address - Fax:805-644-1501
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16839111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition