Provider Demographics
NPI:1588978811
Name:ROTACH, AUTUM LEIGH (LAC)
Entity type:Individual
Prefix:
First Name:AUTUM
Middle Name:LEIGH
Last Name:ROTACH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:BARNEVELD
Mailing Address - State:NY
Mailing Address - Zip Code:13304-2911
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10700 JOHN ST
Practice Address - Street 2:
Practice Address - City:BARNEVELD
Practice Address - State:NY
Practice Address - Zip Code:13304-2911
Practice Address - Country:US
Practice Address - Phone:917-455-2032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004409171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist