Provider Demographics
NPI:1720200116
Name:THE ROESKE CLINIC, PC
Entity Type:Organization
Organization Name:THE ROESKE CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICH
Authorized Official - Middle Name:
Authorized Official - Last Name:ROESKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DABCO, DABCN
Authorized Official - Phone:770-435-0200
Mailing Address - Street 1:757 CONCORD RD SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-2626
Mailing Address - Country:US
Mailing Address - Phone:770-435-0200
Mailing Address - Fax:770-435-4362
Practice Address - Street 1:757 CONCORD RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-2626
Practice Address - Country:US
Practice Address - Phone:770-435-0200
Practice Address - Fax:770-435-4362
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR001242111NN0400X, 111NX0800X
GACHIR001370111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Multi-Specialty
No111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty