Provider Demographics
NPI:1639690779
Name:ROARK, GREGORY ALLEN (MS, ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ALLEN
Last Name:ROARK
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 SETTLERS WAY
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-7410
Mailing Address - Country:US
Mailing Address - Phone:214-207-2963
Mailing Address - Fax:
Practice Address - Street 1:909 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1520
Practice Address - Country:US
Practice Address - Phone:214-820-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT27412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer