Healthcare Provider Details

I. General information

NPI: 1316490022
Provider Name (Legal Business Name): JANICE ROTH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2016
Last Update Date: 07/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

669 AGENCY MAIN ST
HARLEM MT
59526-9455
US

IV. Provider business mailing address

669 AGENCY MAIN ST
HARLEM MT
59526-9455
US

V. Phone/Fax

Practice location:
  • Phone: 406-353-3100
  • Fax:
Mailing address:
  • Phone: 406-353-3100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN23156
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: