1538250634 NPI number — ROSE OF SHARON MEDICAL SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538250634 NPI number — ROSE OF SHARON MEDICAL SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE OF SHARON MEDICAL SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538250634
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2125 MCCULLOCH BLVD N
Provider Second Line Business Mailing Address:
STE B
Provider Business Mailing Address City Name:
LAKE HAVASU CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86403-5899
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-855-8655
Provider Business Mailing Address Fax Number:
928-505-4653

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2125 MCCULLOCH BLVD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
LAKE HAVASU CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
86403-5899
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-855-8655
Provider Business Practice Location Address Fax Number:
928-505-4653
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RIBAUDO
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
928-855-8655

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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