Provider Demographics
NPI:1740490069
Name:MATTHEW G ROACH D C A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MATTHEW G ROACH D C A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:G
Authorized Official - Last Name:ROACH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:702-871-3420
Mailing Address - Street 1:5650 W FLAMINGO RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-0172
Mailing Address - Country:US
Mailing Address - Phone:702-871-3420
Mailing Address - Fax:
Practice Address - Street 1:5650 W FLAMINGO RD
Practice Address - Street 2:SUITE A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-0172
Practice Address - Country:US
Practice Address - Phone:702-871-3420
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-23
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB-704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV33224Medicare PIN
NVU79427Medicare UPIN