Healthcare Provider Details

I. General information

NPI: 1053174094
Provider Name (Legal Business Name): MRS. ANGELA MICHELLE ROTRUCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2024
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26780 STATE ROUTE 93
FRESNO OH
43824-9793
US

IV. Provider business mailing address

26780 STATE ROUTE 93
FRESNO OH
43824-9793
US

V. Phone/Fax

Practice location:
  • Phone: 740-202-2655
  • Fax:
Mailing address:
  • Phone: 740-202-2655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: