Provider Demographics
NPI:1780954644
Name:AZMANOVA, ROZA KOSTADINOVA (LAC)
Entity type:Individual
Prefix:
First Name:ROZA
Middle Name:KOSTADINOVA
Last Name:AZMANOVA
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 1:1735 WICKE AVE
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60018-1716
Mailing Address - Country:US
Mailing Address - Phone:224-381-6319
Mailing Address - Fax:
Practice Address - Street 1:1400 RENAISSANCE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1329
Practice Address - Country:US
Practice Address - Phone:224-381-6319
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000872171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist