Provider Demographics
NPI:1033326541
Name:ROSE CLINIC A PROFESIONAL MEDICAL CORP
Entity type:Organization
Organization Name:ROSE CLINIC A PROFESIONAL MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:STRYKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-755-8955
Mailing Address - Street 1:530 LOMAS SANTA FE DR
Mailing Address - Street 2:B-1
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1349
Mailing Address - Country:US
Mailing Address - Phone:858-755-8955
Mailing Address - Fax:858-755-8959
Practice Address - Street 1:530 LOMAS SANTA FE DR
Practice Address - Street 2:B-1
Practice Address - City:SOLANA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92075-1349
Practice Address - Country:US
Practice Address - Phone:858-755-8955
Practice Address - Fax:858-755-8959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG854562085D0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG4917Medicare UPIN