Provider Demographics
NPI:1710280490
Name:ROTH CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:ROTH CHIROPRACTIC PLLC
Other - Org Name:ROTH CHIROPRACTIC SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:TACYSHYN-ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-916-3506
Mailing Address - Street 1:315 SE MAIN ST APT 412
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-4222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 SE MAIN ST APT 412
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-4222
Practice Address - Country:US
Practice Address - Phone:612-916-3506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI2869111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty