Healthcare Provider Details

I. General information

NPI: 1790230290
Provider Name (Legal Business Name): MIRANDA JANE ROSEN P.T., D.P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2016
Last Update Date: 08/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6930 WARNER AVE
HUNTINGTON BEACH CA
92647-5316
US

IV. Provider business mailing address

5852 MEADOWBROOK DR
HUNTINGTON BEACH CA
92649-3719
US

V. Phone/Fax

Practice location:
  • Phone: 714-847-3800
  • Fax:
Mailing address:
  • Phone: 714-609-4004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT291687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: