Provider Demographics
NPI:1790061000
Name:ROTH, SHAWN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:CHRISTOPHER
Last Name:ROTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 SAWTELLE BLVD APT 315
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-1421
Mailing Address - Country:US
Mailing Address - Phone:951-202-4785
Mailing Address - Fax:
Practice Address - Street 1:1035 E MARSHALL PL
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3619
Practice Address - Country:US
Practice Address - Phone:951-202-4785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-31
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
CAPT38671225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist