Healthcare Provider Details

I. General information

NPI: 1033316419
Provider Name (Legal Business Name): BRENT A ROTH DC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W HIGH ST
HICKSVILLE OH
43526-1083
US

IV. Provider business mailing address

501 W HIGH ST
HICKSVILLE OH
43526-1083
US

V. Phone/Fax

Practice location:
  • Phone: 419-542-8247
  • Fax: 419-542-6726
Mailing address:
  • Phone: 419-542-8247
  • Fax: 419-542-6716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number719
License Number StateOH

VIII. Authorized Official

Name: BRENT A ROTH
Title or Position: PRESIDENT
Credential: DC
Phone: 419-542-8247