Healthcare Provider Details

I. General information

NPI: 1255572889
Provider Name (Legal Business Name): ELAINE ROACH LD/N MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 08/19/2021
Certification Date: 08/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9680 PINES BLVD
PEMBROKE PINES FL
33024-6246
US

IV. Provider business mailing address

PO BOX 170084
HIALEAH FL
33017-0084
US

V. Phone/Fax

Practice location:
  • Phone: 954-367-6192
  • Fax: 954-342-9624
Mailing address:
  • Phone: 954-367-6192
  • Fax: 305-816-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code133VN1101X
TaxonomyGerontological Nutrition Registered Dietitian
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: