Provider Demographics
NPI:1508262882
Name:ROACH, JON-TYLER (DC)
Entity Type:Individual
Prefix:DR
First Name:JON-TYLER
Middle Name:
Last Name:ROACH
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 1:6468 FARMDALE RD
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1330
Mailing Address - Country:US
Mailing Address - Phone:304-733-4038
Mailing Address - Fax:304-733-4036
Practice Address - Street 1:6468 FARMDALE RD
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1330
Practice Address - Country:US
Practice Address - Phone:304-733-4038
Practice Address - Fax:304-733-4036
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV973111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor