Provider Demographics
NPI:1760791511
Name:ROACH, DANIEL L (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:ROACH
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 1:704 N STATE HIGHWAY 47
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-1108
Mailing Address - Country:US
Mailing Address - Phone:636-400-3213
Mailing Address - Fax:
Practice Address - Street 1:704 N STATE HIGHWAY 47
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-1108
Practice Address - Country:US
Practice Address - Phone:636-400-3213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-28
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO225000000X, 332B00000X
MO2010033249111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO830068901Medicaid