MEDICARE: DR. KEVIN M ROACH D.C.

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	111N00000X	Chiropractor	2008001506	MO

General Provider Information

NPI Number	:	1093984825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEVIN M ROACH D.C.

Provider Business Mailing Address
First Line	:	3221 DOMAIN ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-8229
Country	:	US
Telephone Number	:	636-724-2742
Fax Number	:

Provider Business Practice Location Address
First Line	:	3221 DOMAIN ST
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63301-8229
Country	:	US
Telephone Number	:	636-724-2742
Fax Number	:

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

Provider Enumeration Date	:	02/26/2008
Last Update Date	:	05/21/2009

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