Healthcare Provider Details

I. General information

NPI: 1083214209
Provider Name (Legal Business Name): DR. KELLY ROTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2020
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 ROUTE 23
FRANKLIN NJ
07416-2008
US

IV. Provider business mailing address

1 LAUREN LN
SUSSEX NJ
07461-4116
US

V. Phone/Fax

Practice location:
  • Phone: 973-209-4253
  • Fax:
Mailing address:
  • Phone: 973-537-9743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number28RI03586900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: