Healthcare Provider Details

I. General information

NPI: 1467202960
Provider Name (Legal Business Name): JULIEANNA ROTH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 HANCES DR
BLACKLICK OH
43004-9260
US

IV. Provider business mailing address

400 HANCES DR
BLACKLICK OH
43004-9260
US

V. Phone/Fax

Practice location:
  • Phone: 708-642-3537
  • Fax:
Mailing address:
  • Phone: 708-642-3537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: