Healthcare Provider Details

I. General information

NPI: 1811148521
Provider Name (Legal Business Name): SCOTT ROIDES AT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LAC DE VILLE BLVD BUILDING D, SUITE 120
ROCHESTER NY
14618-5647
US

IV. Provider business mailing address

4901 LAC DE VILLE BLVD BUILDING D, SUITE 120
ROCHESTER NY
14618-5647
US

V. Phone/Fax

Practice location:
  • Phone: 585-341-9250
  • Fax:
Mailing address:
  • Phone: 585-341-9250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number089302533
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: