Provider Demographics
NPI:1699023135
Name:WILLIAMSBURG NECK AND BACK CENTER LLC
Entity Type:Organization
Organization Name:WILLIAMSBURG NECK AND BACK CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-345-6562
Mailing Address - Street 1:4808 COURTHOUSE ST
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2684
Mailing Address - Country:US
Mailing Address - Phone:757-345-6562
Mailing Address - Fax:757-345-6516
Practice Address - Street 1:4808 COURTHOUSE ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-2684
Practice Address - Country:US
Practice Address - Phone:757-345-6562
Practice Address - Fax:757-345-6516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556654111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty