Healthcare Provider Details

I. General information

NPI: 1538114046
Provider Name (Legal Business Name): LIBERTY CIRCLE EAR NOSE & THROAT INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 1ST AVE
HUNTINGTON WV
25702-1241
US

IV. Provider business mailing address

96 TOWNSHIP ROAD 369 SUITE 101
PROCTORVILLE OH
45669
US

V. Phone/Fax

Practice location:
  • Phone: 740-886-9370
  • Fax: 740-886-9374
Mailing address:
  • Phone: 740-886-9370
  • Fax: 740-886-9374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number17624
License Number StateWV

VIII. Authorized Official

Name: DR. RICARDO ARTURO ROA
Title or Position: SOLE MEMBER/MEDICAL DIRECTOR
Credential: M.D.
Phone: 740-886-9370