Healthcare Provider Details

I. General information

NPI: 1134304637
Provider Name (Legal Business Name): ROSEBUD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2008
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3225 E YUCCA ST
PHOENIX AZ
85028-2707
US

IV. Provider business mailing address

3225 E YUCCA ST
PHOENIX AZ
85028-2707
US

V. Phone/Fax

Practice location:
  • Phone: 602-750-6743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: PAMELA L WALLEN LYNCH
Title or Position: CEO
Credential:
Phone: 602-750-6743