=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063969558
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARRICK STEWART ROACH
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2016
-----------------------------------------------------
Last Update Date | 09/01/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1225 MARSHALL ST. 18
-----------------------------------------------------
City | CRESCENT CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-954-8978
-----------------------------------------------------
Fax | 707-460-1401
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1225 MARSHALL ST. 18
-----------------------------------------------------
City | CRESCENT CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-954-8978
-----------------------------------------------------
Fax | 707-460-1401
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 64848
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------