Healthcare Provider Details

I. General information

NPI: 1760791511
Provider Name (Legal Business Name): DANIEL L ROACH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2010
Last Update Date: 07/29/2022
Certification Date: 07/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 N STATE HIGHWAY 47
WARRENTON MO
63383-1108
US

IV. Provider business mailing address

704 N STATE HIGHWAY 47
WARRENTON MO
63383-1108
US

V. Phone/Fax

Practice location:
  • Phone: 636-400-3213
  • Fax:
Mailing address:
  • Phone: 636-400-3213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2010033249
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: