MEDICARE: CAMMIE L ROACH

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

General Provider Information

NPI Number	:	1417557984
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMMIE L ROACH

Provider Business Mailing Address
First Line	:	1029 PINE ST
Second Line	:
City	:	SAINT ALBANS
State	:	WV
Zip	:	25177-8380
Country	:	US
Telephone Number	:	304-721-9148
Fax Number	:

Provider Business Practice Location Address
First Line	:	1029 PINE ST
Second Line	:
City	:	SAINT ALBANS
State	:	WV
Zip	:	25177-8380
Country	:	US
Telephone Number	:	304-721-9148
Fax Number	:

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

Provider Enumeration Date	:	10/26/2020
Last Update Date	:	04/29/2022

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Directions to “ CAMMIE L ROACH ” Practice Location

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