Provider Demographics
NPI:1982735478
Name:ROACH, CINDY LOU II
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:LOU
Last Name:ROACH
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-1016
Mailing Address - Country:US
Mailing Address - Phone:440-645-7829
Mailing Address - Fax:
Practice Address - Street 1:31900 N MARGINAL DR
Practice Address - Street 2:
Practice Address - City:WILLOWICK
Practice Address - State:OH
Practice Address - Zip Code:44095-4427
Practice Address - Country:US
Practice Address - Phone:440-347-0209
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH105189477099Medicaid
OH105189477099Medicaid