Healthcare Provider Details

I. General information

NPI: 1346561693
Provider Name (Legal Business Name): ANTHONY JOE ROFFINE M.M.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6108 S 31ST ST
FORT SMITH AR
72908-7555
US

IV. Provider business mailing address

6108 S 31ST ST
FORT SMITH AR
72908-7555
US

V. Phone/Fax

Practice location:
  • Phone: 479-648-1107
  • Fax: 479-646-0416
Mailing address:
  • Phone: 479-648-1107
  • Fax: 479-646-0416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1470
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: