Provider Demographics
NPI:1861783847
Name:ROTH MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:ROTH MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:TERRENCE
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-483-4403
Mailing Address - Street 1:220 E ROWAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99207-1203
Mailing Address - Country:US
Mailing Address - Phone:509-483-4403
Mailing Address - Fax:509-489-7556
Practice Address - Street 1:220 E ROWAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99207-1203
Practice Address - Country:US
Practice Address - Phone:509-483-4403
Practice Address - Fax:509-489-7556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00035230261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1111145Medicaid
WA1111145Medicaid