Healthcare Provider Details

I. General information

NPI: 1811020126
Provider Name (Legal Business Name): JEFFERSON A ROTH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41191 US HWY 6 & 24
AVON CO
81620
US

IV. Provider business mailing address

PO BOX 699
VAIL CO
81658-0699
US

V. Phone/Fax

Practice location:
  • Phone: 970-949-6244
  • Fax: 970-949-6325
Mailing address:
  • Phone: 970-949-6244
  • Fax: 970-949-6325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1557
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: