Provider Demographics
NPI:1912321357
Name:ROTH FAMILY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:ROTH FAMILY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-829-0707
Mailing Address - Street 1:355 NEW BRITAIN RD
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1318
Mailing Address - Country:US
Mailing Address - Phone:860-829-0707
Mailing Address - Fax:860-829-0606
Practice Address - Street 1:355 NEW BRITAIN RD
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:CT
Practice Address - Zip Code:06037-1318
Practice Address - Country:US
Practice Address - Phone:860-829-0707
Practice Address - Fax:860-829-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-05
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001773111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty