Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 16839 | CA |
NPI | 1114175551 |
---|---|
Provider Name | Michael Roth |
First Address | Ventura, CA 93003-6531 |
Second Address | Ventura, CA 93003-6531 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/08/2008 |
Last Update Date | 27/08/2008 |