MEDICARE: DR. JEONGHO ROH 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	DC25267	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DC25267	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1689860785
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEONGHO ROH D.C.

Provider Business Mailing Address
First Line	:	18726 S WESTERN AVE
Second Line	:	SUITE 402
City	:	GARDENA
State	:	CA
Zip	:	90248-3813
Country	:	US
Telephone Number	:	310-218-7634
Fax Number	:	310-400-3059

Provider Business Practice Location Address
First Line	:	18726 S WESTERN AVE
Second Line	:	SUITE 402
City	:	GARDENA
State	:	CA
Zip	:	90248-3813
Country	:	US
Telephone Number	:	310-218-7634
Fax Number	:	310-400-3059

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

Provider Enumeration Date	:	09/21/2007
Last Update Date	:	07/01/2013

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