Provider Demographics
NPI:1578704458
Name:ROACH FAMILY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ROACH FAMILY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:407-647-2009
Mailing Address - Street 1:251 N MAITLAND AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4914
Mailing Address - Country:US
Mailing Address - Phone:407-647-2009
Mailing Address - Fax:407-660-2009
Practice Address - Street 1:251 N MAITLAND AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701-4914
Practice Address - Country:US
Practice Address - Phone:407-647-2009
Practice Address - Fax:407-660-2009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-23
Last Update Date:2010-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9409111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002190400Medicaid
FL002190400Medicaid
FLBT435Medicare PIN