Healthcare Provider Details

I. General information

NPI: 1467524462
Provider Name (Legal Business Name): ANGELA IVY ROSEN L.AC.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 03/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1911 ADDISON ST SUITE 201
BERKELEY CA
94704-1267
US

IV. Provider business mailing address

177 HANNA WAY
MENLO PARK CA
94025-3581
US

V. Phone/Fax

Practice location:
  • Phone: 510-517-6858
  • Fax:
Mailing address:
  • Phone: 510-517-6858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number10848
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: