Provider Demographics
NPI:1306881263
Name:ROTHALL, INC.
Entity type:Organization
Organization Name:ROTHALL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-564-5333
Mailing Address - Street 1:1951 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81004-3321
Mailing Address - Country:US
Mailing Address - Phone:719-564-5333
Mailing Address - Fax:719-564-6133
Practice Address - Street 1:1951 LAKE AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3321
Practice Address - Country:US
Practice Address - Phone:719-564-5333
Practice Address - Fax:719-564-6133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-17
Last Update Date:2016-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171WH0202X
CO03-49440-0000332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO08000994Medicaid
CO0627390001Medicare NSC