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NPI Code Detail

MEDICARE: NICOLE BROOK ROACH PTA, LMT

MEDICARE: NICOLE BROOK ROACH PTA, LMT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225200000XPhysical Therapy Assistant2018037409MO

General Provider Information

NPI Number : 1275004210
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE BROOK ROACH PTA, LMT
Provider Business Mailing Address
First Line : 2223 BUEHRLE DR
Second Line :
City : JEFFERSON CITY
State : MO
Zip : 65109-1926
Country : US
Telephone Number : 573-462-0853
Fax Number :
Provider Business Practice Location Address
First Line : 1720 VIETH DR
Second Line :
City : JEFFERSON CITY
State : MO
Zip : 65109-2056
Country : US
Telephone Number : 573-635-6139
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/17/2018
Last Update Date : 12/17/2018

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