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General NPI Number Information
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NPI Number | 1710697818
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Entity Type | Individual
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Provider Name | RICKEY ROACH
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Gender | Male
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Dates
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Enumeration Date | 11/29/2022
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Last Update Date | 11/29/2022
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Provider Practice Location Address
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Address Line | 2928 N 55TH ST
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City | MILWAUKEE
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State | WI
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Zip | 53210-1561
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Country | US
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Telephone | 414-766-8072
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 241003
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City | MILWAUKEE
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State | WI
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Zip | 53224-9025
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Country | US
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Telephone | 414-766-8072
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Fax | 414-231-3734
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | 0019066
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License Number State | WI
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