Provider Demographics
NPI:1770849929
Name:ROTH, STACEY (DC)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:
Last Name:ROTH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1906 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-5210
Mailing Address - Country:US
Mailing Address - Phone:218-233-2517
Mailing Address - Fax:
Practice Address - Street 1:1906 30TH AVE S
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560-5210
Practice Address - Country:US
Practice Address - Phone:218-233-2517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3114111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor