MEDICARE: MRS. ANNETTE ROACH RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant	070503	MO

General Provider Information

NPI Number	:	1003087842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANNETTE ROACH RN

Provider Business Mailing Address
First Line	:	5449 ARLINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63120-2520
Country	:	US
Telephone Number	:	314-385-1965
Fax Number	:	314-381-3199

Provider Business Practice Location Address
First Line	:	5449 ARLINGTON AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63120-2520
Country	:	US
Telephone Number	:	314-385-1965
Fax Number	:	314-381-3199

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/19/2008
Last Update Date	:	03/19/2008

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