Healthcare Provider Details

I. General information

NPI: 1124570486
Provider Name (Legal Business Name): ROBERT C ROTH B.S., M.S., ACSM-CPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2016
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 HICKORY ST NW
ALBANY OR
97321-1726
US

IV. Provider business mailing address

401 S 15TH ST
PHILOMATH OR
97370-9205
US

V. Phone/Fax

Practice location:
  • Phone: 541-812-3302
  • Fax:
Mailing address:
  • Phone: 503-680-3549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1043016
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: