Provider Demographics
NPI:1881109833
Name:ROATH, BRIAN ANDREW (PT, DPT)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:ANDREW
Last Name:ROATH
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TENNESSEE ST APT B
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4482
Mailing Address - Country:US
Mailing Address - Phone:909-557-0762
Mailing Address - Fax:
Practice Address - Street 1:13313 PALM DR STE B
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-5980
Practice Address - Country:US
Practice Address - Phone:760-671-4760
Practice Address - Fax:760-671-4798
Is Sole Proprietor?:No
Enumeration Date:2017-12-12
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT40932225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist