Provider Demographics
NPI:1528548583
Name:ROACH, ALLISON
Entity Type:Individual
Prefix:
First Name:ALLISON
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 1:3805 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1117
Mailing Address - Country:US
Mailing Address - Phone:806-687-5670
Mailing Address - Fax:806-687-5673
Practice Address - Street 1:3805 22ND PL
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1117
Practice Address - Country:US
Practice Address - Phone:806-687-5670
Practice Address - Fax:806-687-5673
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT05798133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty