Provider Demographics
NPI:1164007662
Name:ROACH, CAROLYN
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:ROACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5378 MEADOW BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RAINELLE
Mailing Address - State:WV
Mailing Address - Zip Code:25962-6061
Mailing Address - Country:US
Mailing Address - Phone:304-663-9541
Mailing Address - Fax:
Practice Address - Street 1:5378 MEADOW BRIDGE RD
Practice Address - Street 2:
Practice Address - City:RAINELLE
Practice Address - State:WV
Practice Address - Zip Code:25962-6061
Practice Address - Country:US
Practice Address - Phone:304-663-9541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker