Provider Demographics
NPI:1780629766
Name:ROTH, DOUGLAS MARK (DC)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:MARK
Last Name:ROTH
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 1:616 BULTMAN DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-2515
Mailing Address - Country:US
Mailing Address - Phone:803-774-2070
Mailing Address - Fax:803-775-8253
Practice Address - Street 1:616 BULTMAN DR
Practice Address - Street 2:SUITE B
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2515
Practice Address - Country:US
Practice Address - Phone:803-774-2070
Practice Address - Fax:803-775-8253
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3063111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor