Healthcare Provider Details

I. General information

NPI: 1922007251
Provider Name (Legal Business Name): GARY ARTHUR ROACH O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date: 03/20/2006
Reactivation Date: 03/23/2006

III. Provider practice location address

404 E CENTER AVE
MOORESVILLE NC
28115-2544
US

IV. Provider business mailing address

404 E CENTER AVE
MOORESVILLE NC
28115-2544
US

V. Phone/Fax

Practice location:
  • Phone: 704-663-3924
  • Fax: 704-663-7057
Mailing address:
  • Phone: 704-663-3924
  • Fax: 704-663-7057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number863
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: