Healthcare Provider Details

I. General information

NPI: 1710998851
Provider Name (Legal Business Name): ROLLER ENTERPRISES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 04/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1691 S BUSINESS HIGHWAY 65
HOLLISTER MO
65672-6342
US

IV. Provider business mailing address

PO BOX 147
HOLLISTER MO
65673-0147
US

V. Phone/Fax

Practice location:
  • Phone: 417-336-3210
  • Fax: 417-336-3201
Mailing address:
  • Phone: 417-336-3210
  • Fax: 417-336-3201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number000740
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License Number000740
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000740
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000740
License Number StateMO

VIII. Authorized Official

Name: JOHN ORVILLE ROLLER
Title or Position: OWNER
Credential: D.P.M.
Phone: 417-336-3210