Provider Demographics
NPI:1699397687
Name:ROTH, JUSTIN NICHOLAS (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:NICHOLAS
Last Name:ROTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21450 HIGHWAY 32 STE A
Mailing Address - Street 2:
Mailing Address - City:SAINTE GENEVIEVE
Mailing Address - State:MO
Mailing Address - Zip Code:63670-8814
Mailing Address - Country:US
Mailing Address - Phone:573-535-1912
Mailing Address - Fax:
Practice Address - Street 1:21450 HIGHWAY 32 STE A
Practice Address - Street 2:
Practice Address - City:SAINTE GENEVIEVE
Practice Address - State:MO
Practice Address - Zip Code:63670-8814
Practice Address - Country:US
Practice Address - Phone:573-535-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-12
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020012884111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor