Basic Information
| Provider Information | |||||||||
| NPI: | 1255572889 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROACH | ||||||||
| FirstName: | ELAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | LD/N MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 170084 | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330170084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543676192 | ||||||||
| FaxNumber: | 3058165844 | ||||||||
| Practice Location | |||||||||
| Address1: | 9680 PINES BLVD | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330246246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543676192 | ||||||||
| FaxNumber: | 9543429624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2009 | ||||||||
| LastUpdateDate: | 08/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | N | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133VN1005X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Renal | 133VN1006X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Metabolic | 133VN1101X | N | 193400000X SINGLE SPECIALTY GROUP | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.