Basic Information
| Provider Information | |||||||||
| NPI: | 1356743215 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLER | ||||||||
| FirstName: | LORY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | ROLLER | ||||||||
| OtherFirstName: | LORAYNE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7671 N PLACITA DE LOS AMIGOS | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857042044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204444428 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6367 E TANQUE VERDE RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857153829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207218800 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2014 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251G0304X | 4279 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
No ID Information.