Provider Demographics
NPI:1740058460
Name:ROA, BARTOLO
Entity type:Individual
Prefix:MR
First Name:BARTOLO
Middle Name:
Last Name:ROA
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 1:166 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-1818
Mailing Address - Country:US
Mailing Address - Phone:773-556-5696
Mailing Address - Fax:
Practice Address - Street 1:166 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-1818
Practice Address - Country:US
Practice Address - Phone:773-556-5696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILR00006075241343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)