Healthcare Provider Details

I. General information

NPI: 1376462200
Provider Name (Legal Business Name): DANIEL GROTH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 MOORMAN AVE NW
ROANOKE VA
24017-5738
US

IV. Provider business mailing address

1114 MOORMAN AVE NW
ROANOKE VA
24017-5738
US

V. Phone/Fax

Practice location:
  • Phone: 540-556-1178
  • Fax:
Mailing address:
  • Phone: 540-556-1178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number2705100660
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: