Provider Demographics
NPI:1255567509
Name:ROACH-GAGNON, TINA MARIE (DC)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:ROACH-GAGNON
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 1:7174 SANTA TERESA BLVD
Mailing Address - Street 2:STE A7
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95139-1350
Mailing Address - Country:US
Mailing Address - Phone:408-972-5686
Mailing Address - Fax:408-972-5682
Practice Address - Street 1:7174 SANTA TERESA BLVD
Practice Address - Street 2:STE A7
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95139-1350
Practice Address - Country:US
Practice Address - Phone:408-972-5686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23580111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition