Provider Demographics
NPI:1356560122
Name:ROTH CHIROPRACTIC, PA
Entity type:Organization
Organization Name:ROTH CHIROPRACTIC, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER,CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:561-392-1777
Mailing Address - Street 1:7064 BERACASA WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3447
Mailing Address - Country:US
Mailing Address - Phone:561-392-1777
Mailing Address - Fax:561-750-2361
Practice Address - Street 1:7064 BERACASA WAY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3447
Practice Address - Country:US
Practice Address - Phone:561-392-1777
Practice Address - Fax:561-750-2361
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 3916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL35005495OtherRR MEDICARE #
FL35005495OtherRR MEDICARE #
FLT55973Medicare UPIN