Healthcare Provider Details

I. General information

NPI: 1104396126
Provider Name (Legal Business Name): MR. JOSHUA RYAN ROTHWELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/03/2018
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 E STATE ROAD 44
SHELBYVILLE IN
46176-1773
US

IV. Provider business mailing address

1209 E STATE ROAD 44
SHELBYVILLE IN
46176-1773
US

V. Phone/Fax

Practice location:
  • Phone: 317-604-5183
  • Fax: 317-291-3376
Mailing address:
  • Phone: 317-604-5183
  • Fax: 317-291-3376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number17001513A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: