Healthcare Provider Details

I. General information

NPI: 1114175551
Provider Name (Legal Business Name): MICHAEL ROTH DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1787 MESA VERDE AVE SUITE 140
VENTURA CA
93003-6531
US

IV. Provider business mailing address

1787 MESA VERDE AVE SUITE 140
VENTURA CA
93003-6531
US

V. Phone/Fax

Practice location:
  • Phone: 805-644-0461
  • Fax: 805-644-1501
Mailing address:
  • Phone: 805-644-0461
  • Fax: 805-644-1501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number16839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: