Healthcare Provider Details

I. General information

NPI: 1053770065
Provider Name (Legal Business Name): KEITH RICHARD ROTH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2016
Last Update Date: 02/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 NORTHVIEW DR
HILLSBORO OH
45133-1184
US

IV. Provider business mailing address

220 MULLIGAN DR
NEW VIENNA OH
45159-9053
US

V. Phone/Fax

Practice location:
  • Phone: 937-393-6163
  • Fax: 937-393-6295
Mailing address:
  • Phone: 440-453-3657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number14950
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: