Healthcare Provider Details

I. General information

NPI: 1629684600
Provider Name (Legal Business Name): CALVIN ROTH III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2020
Last Update Date: 09/16/2020
Certification Date: 09/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 SWIERKOS DR
MOUNDSVILLE WV
26041-4209
US

IV. Provider business mailing address

215 PARRIOTT AVE
MOUNDSVILLE WV
26041-1618
US

V. Phone/Fax

Practice location:
  • Phone: 304-843-0910
  • Fax:
Mailing address:
  • Phone: 304-840-0910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: