Basic Information
Provider Information | |||||||||
NPI: | 1710443833 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SIRACH HEALTH PROFESSIONAL LIMITED LIABILITY COMPANY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SIRACH HEALTH LLC | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 847 | ||||||||
Address2: |   | ||||||||
City: | CORDOVA | ||||||||
State: | TN | ||||||||
PostalCode: | 380880847 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9018210338 | ||||||||
FaxNumber: | 8443250416 | ||||||||
Practice Location | |||||||||
Address1: | 4070 US HIGHWAY 17 BYPASS SOUTH | ||||||||
Address2: |   | ||||||||
City: | MURRELLS INLET | ||||||||
State: | SC | ||||||||
PostalCode: | 29576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8653068363 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/13/2019 | ||||||||
LastUpdateDate: | 04/24/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ROQUE | ||||||||
AuthorizedOfficialFirstName: | JOEY | ||||||||
AuthorizedOfficialMiddleName: | EDWARD MALONJARO | ||||||||
AuthorizedOfficialTitleorPosition: | CEO, SOLE MEMBER | ||||||||
AuthorizedOfficialTelephone: | 8653068363 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   |
No ID Information.