Provider Demographics
NPI:1508916230
Name:ROTH, RICHARD CHARLES (DC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:CHARLES
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 1:655 CAMINO DE LOS MARES STE 121
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2809
Mailing Address - Country:US
Mailing Address - Phone:949-498-3262
Mailing Address - Fax:949-498-4718
Practice Address - Street 1:655 CAMINO DE LOS MARES STE 121
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2809
Practice Address - Country:US
Practice Address - Phone:949-498-3262
Practice Address - Fax:949-498-4718
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14746111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0147460OtherBLUE SHIELD
CADC14746OtherCHIROPRACTIC LICENSE
CADC14746Medicare ID - Type Unspecified