MEDICARE: MRS. KELLY LYNN ROACH PTA

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	225200000X	Physical Therapy Assistant	0224	SD

General Provider Information

NPI Number	:	1689862658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY LYNN ROACH PTA

Provider Business Mailing Address
First Line	:	3335 PALM DR APT 1
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-2069
Country	:	US
Telephone Number	:	605-390-8545
Fax Number	:

Provider Business Practice Location Address
First Line	:	3335 PALM DR APT 1
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57701-2069
Country	:	US
Telephone Number	:	605-390-8545
Fax Number	:

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

Provider Enumeration Date	:	10/04/2007
Last Update Date	:	10/04/2007

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