Provider Demographics
NPI:1124570486
Name:ROTH, ROBERT C (BS, MS, ACSM-CPT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:C
Last Name:ROTH
Suffix:
Gender:M
Credentials:BS, MS, ACSM-CPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILOMATH
Mailing Address - State:OR
Mailing Address - Zip Code:97370-9205
Mailing Address - Country:US
Mailing Address - Phone:503-680-3549
Mailing Address - Fax:
Practice Address - Street 1:380 HICKORY ST NW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1726
Practice Address - Country:US
Practice Address - Phone:541-812-3302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1043016174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist