Provider Demographics
NPI:1922579648
Name:ROE, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:ROE
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 1:57986 195TH AVE
Mailing Address - Street 2:
Mailing Address - City:DODGE CENTER
Mailing Address - State:MN
Mailing Address - Zip Code:55927-7904
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:57986 195TH AVE
Practice Address - Street 2:
Practice Address - City:DODGE CENTER
Practice Address - State:MN
Practice Address - Zip Code:55927
Practice Address - Country:US
Practice Address - Phone:507-273-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer