1366564536 NPI number — MS. CARLA J ROTH CADC, CADAC IV, LCAC

Table of content: MS. CARLA J ROTH CADC, CADAC IV, LCAC (NPI 1366564536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366564536 NPI number — MS. CARLA J ROTH CADC, CADAC IV, LCAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROTH
Provider First Name:
CARLA
Provider Middle Name:
J
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CADC, CADAC IV, LCAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAYVAULT
Provider Other First Name:
CARLA
Provider Other Middle Name:
S
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CADC, CADAC IV
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366564536
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 W COURT AVE
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
JEFFERSONVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47130-3502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-207-8633
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 W COURT AVE
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
JEFFERSONVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47130-3502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-207-8633
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  87000608A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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