Provider Demographics
NPI:1225056740
Name:ROTH, LAURIE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:ROTH
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 1:55 VAN TASSEL DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-6177
Mailing Address - Country:US
Mailing Address - Phone:704-408-1442
Mailing Address - Fax:
Practice Address - Street 1:55 VAN TASSEL DR
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786-6177
Practice Address - Country:US
Practice Address - Phone:704-408-1442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3076111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC085JPOtherBLUE CROSS BLUE SHEILD
NC561971088OtherCNC
NC89085JPMedicaid
NC62871OtherACN
NC62871OtherACN
NC2345264Medicare PIN