MEDICARE: ROTH CHIROPRACTIC PLLC

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	WI2869	WI

General Provider Information

NPI Number	:	1710280490
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROTH CHIROPRACTIC PLLC

Provider Business Mailing Address
First Line	:	315 SE MAIN ST APT 412
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4222
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	315 SE MAIN ST APT 412
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55414-4222
Country	:	US
Telephone Number	:	612-916-3506
Fax Number	:

Authorized Official
Title or Position	:	DR./OWNER
Name	:	JAMES ARTHUR TACYSHYN-ROTH
Credential	:	D.C.
Telephone Number	:	612-916-3506

Provider Enumeration Date	:	12/17/2010
Last Update Date	:	03/07/2018

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