Provider Demographics
NPI:1558631945
Name:ROTH CHIROPRACTIC CLINIC LTD
Entity Type:Organization
Organization Name:ROTH CHIROPRACTIC CLINIC LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARS
Authorized Official - Middle Name:LYLE
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:218-365-5770
Mailing Address - Street 1:39 E SHERIDAN ST
Mailing Address - Street 2:P.O. BOX 659
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731-1213
Mailing Address - Country:US
Mailing Address - Phone:218-365-5770
Mailing Address - Fax:218-365-5770
Practice Address - Street 1:39 E SHERIDAN ST
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731-1213
Practice Address - Country:US
Practice Address - Phone:218-365-5770
Practice Address - Fax:218-365-5770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ROTH CHIROPRACTIC CLINIC LTD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-03
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1263111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN908225500Medicaid
359000839Medicare PIN