Provider Demographics
NPI:1710443833
Name:SIRACH HEALTH PROFESSIONAL LIMITED LIABILITY COMPANY
Entity Type:Organization
Organization Name:SIRACH HEALTH PROFESSIONAL LIMITED LIABILITY COMPANY
Other - Org Name:SIRACH HEALTH LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO, SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:EDWARD MALONJARO
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:865-306-8363
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38088-0847
Mailing Address - Country:US
Mailing Address - Phone:901-821-0338
Mailing Address - Fax:844-325-0416
Practice Address - Street 1:4070 US HIGHWAY 17 BYPASS SOUTH
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576
Practice Address - Country:US
Practice Address - Phone:865-306-8363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-13
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty