Provider Demographics
NPI:1710998851
Name:ROLLER ENTERPRISES LLC
Entity Type:Organization
Organization Name:ROLLER ENTERPRISES LLC
Other - Org Name:JOHN O. ROLLER, DPM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ORVILLE
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:417-336-3210
Mailing Address - Street 1:PO BOX 147
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:MO
Mailing Address - Zip Code:65673-0147
Mailing Address - Country:US
Mailing Address - Phone:417-336-3210
Mailing Address - Fax:417-336-3201
Practice Address - Street 1:1691 S BUSINESS HIGHWAY 65
Practice Address - Street 2:
Practice Address - City:HOLLISTER
Practice Address - State:MO
Practice Address - Zip Code:65672-6342
Practice Address - Country:US
Practice Address - Phone:417-336-3210
Practice Address - Fax:417-336-3201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2012-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000740213E00000X, 213EP1101X, 213ER0200X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DF3458OtherRR MCR
MO507427300Medicaid
CH2570OtherRR MCR
DF3458OtherRR MCR
MO507427300Medicaid
MO5842230001Medicare NSC