Healthcare Provider Details

I. General information

NPI: 1366998635
Provider Name (Legal Business Name): ROLAND SPENCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 08/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44400 WILLIS AVE.
LAYTONVILLE CA
95454
US

IV. Provider business mailing address

PO BOX 211
LAYTONVILLE CA
95454-0211
US

V. Phone/Fax

Practice location:
  • Phone: 707-984-8089
  • Fax:
Mailing address:
  • Phone: 707-984-8089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: