Healthcare Provider Details

I. General information

NPI: 1326751272
Provider Name (Legal Business Name): LISA ROACH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 JACK BURLINGAME DR
MILLWOOD WV
25262-8576
US

IV. Provider business mailing address

PO BOX 1031
NEW HAVEN WV
25265-1031
US

V. Phone/Fax

Practice location:
  • Phone: 304-273-9311
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: