Provider Demographics
NPI:1558431023
Name:ROACH, JOHNNY W (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:W
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 1:1406 SW 89TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-6305
Mailing Address - Country:US
Mailing Address - Phone:405-605-2532
Mailing Address - Fax:405-605-2534
Practice Address - Street 1:1406 SW 89TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6305
Practice Address - Country:US
Practice Address - Phone:405-605-2532
Practice Address - Fax:405-605-2534
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2634111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor