Provider Demographics
NPI:1598325946
Name:304 CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:304 CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON-TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-638-3160
Mailing Address - Street 1:6468 FARMDALE RD
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1330
Mailing Address - Country:US
Mailing Address - Phone:304-733-4038
Mailing Address - Fax:304-733-4036
Practice Address - Street 1:6468 FARMDALE RD
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1330
Practice Address - Country:US
Practice Address - Phone:304-743-1261
Practice Address - Fax:304-390-6015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-18
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty