Healthcare Provider Details

I. General information

NPI: 1053216317
Provider Name (Legal Business Name): TRACY ROACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7760 EXCELSIOR RD STE 104
BAXTER MN
56425-9768
US

IV. Provider business mailing address

7760 EXCELSIOR RD STE 104
BAXTER MN
56425-9768
US

V. Phone/Fax

Practice location:
  • Phone: 407-982-4876
  • Fax: 407-650-2758
Mailing address:
  • Phone: 407-982-4876
  • Fax: 407-650-2758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: