Provider Demographics
NPI:1770781072
Name:ROACH, ERIK D (DC)
Entity type:Individual
Prefix:DR
First Name:ERIK
Middle Name:D
Last Name:ROACH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 VISTA OAK DR
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-3067
Mailing Address - Country:US
Mailing Address - Phone:407-678-2009
Mailing Address - Fax:407-660-2009
Practice Address - Street 1:623 MAITLAND AVE STE 1101
Practice Address - Street 2:
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701
Practice Address - Country:US
Practice Address - Phone:407-678-2009
Practice Address - Fax:407-660-2009
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-07
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4318-12111N00000X
FLCH9409111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002190400Medicaid
FL002190400Medicaid
FLBT540 AMedicare UPIN