MEDICARE: LISA ROTH

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	376K00000X	Nurse's Aide	100656A	MO

General Provider Information

NPI Number	:	1346612272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ROTH

Provider Business Mailing Address
First Line	:	22294 COFFELT RD
Second Line	:
City	:	SAINT MARY
State	:	MO
Zip	:	63673-9225
Country	:	US
Telephone Number	:	573-535-4538
Fax Number	:

Provider Business Practice Location Address
First Line	:	22294 COFFELT RD
Second Line	:
City	:	SAINT MARY
State	:	MO
Zip	:	63673-9225
Country	:	US
Telephone Number	:	573-535-4538
Fax Number	:

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

Provider Enumeration Date	:	10/30/2015
Last Update Date	:	10/30/2015

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Directions to “ LISA ROTH ” Practice Location

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