Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251X0800X | Physical Therapist - Orthopedic | 1166590 | TX |
NPI | 1063907996 |
---|---|
Provider Name | Mr. Jeffrey Alan Roche |
First Address | Vidor, TX 77662-2957 |
Second Address | Beaumont, TX 77706-7285 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/06/2018 |
Last Update Date | 23/06/2018 |