Basic Information
| Provider Information | |||||||||
| NPI: | 1821663006 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTH | ||||||||
| FirstName: | RILEY | ||||||||
| MiddleName: | NOELLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20302 43RD AVE E | ||||||||
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| City: | SPANAWAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983876718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2536829519 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1816 EAGLE DR STE 100-C | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301898273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7705169191 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2021 | ||||||||
| LastUpdateDate: | 05/20/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA7366 | ID | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.