Healthcare Provider Details

I. General information

NPI: 1124055934
Provider Name (Legal Business Name): JEFFREY BRIAN ROISTACHER DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 05/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 FALLS OF NEUSE RD SUITE 100
RALEIGH NC
27615-3548
US

IV. Provider business mailing address

8450 FALLS OF NEUSE RD SUITE 100
RALEIGH NC
27615-3548
US

V. Phone/Fax

Practice location:
  • Phone: 919-847-3959
  • Fax:
Mailing address:
  • Phone: 919-847-3959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4179
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: