Healthcare Provider Details

I. General information

NPI: 1952677080
Provider Name (Legal Business Name): ROACH ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2012
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 FRISCO ST
MARKED TREE AR
72365-2214
US

IV. Provider business mailing address

50 FRISCO ST
MARKED TREE AR
72365-2214
US

V. Phone/Fax

Practice location:
  • Phone: 870-358-2484
  • Fax:
Mailing address:
  • Phone: 870-358-2484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DONNI J ROACH
Title or Position: PRESIDENT
Credential: PD
Phone: 870-358-2484