Provider Demographics
NPI:1821107541
Name:ROTH, LARS LYLE
Entity Type:Individual
Prefix:DR
First Name:LARS
Middle Name:LYLE
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:PO BOX 659
Mailing Address - Street 2:
Mailing Address - City:ELY
Mailing Address - State:MN
Mailing Address - Zip Code:55731
Mailing Address - Country:US
Mailing Address - Phone:218-365-5770
Mailing Address - Fax:
Practice Address - Street 1:39 E SHERIDAN
Practice Address - Street 2:
Practice Address - City:ELY
Practice Address - State:MN
Practice Address - Zip Code:55731
Practice Address - Country:US
Practice Address - Phone:218-365-5770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01263111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN73220R0OtherBCBS OF MN
MN908225500OtherMN HEALTH CARE PROGRAMS
359000839Medicare ID - Type Unspecified