Healthcare Provider Details

I. General information

NPI: 1306881263
Provider Name (Legal Business Name): ROTHALL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 11/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1951 LAKE AVE
PUEBLO CO
81004-3321
US

IV. Provider business mailing address

1951 LAKE AVE
PUEBLO CO
81004-3321
US

V. Phone/Fax

Practice location:
  • Phone: 719-564-5333
  • Fax: 719-564-6133
Mailing address:
  • Phone: 719-564-5333
  • Fax: 719-564-6133

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number03-49440-0000
License Number StateCO

VIII. Authorized Official

Name: MR. RICHARD W ROTH
Title or Position: OWNER
Credential:
Phone: 719-564-5333