Healthcare Provider Details

I. General information

NPI: 1174969232
Provider Name (Legal Business Name): RENEE ELAINE ROSE-LYNVILLE CAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2013
Last Update Date: 05/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 BEACH COURT
LOTUS CA
95613
US

IV. Provider business mailing address

P.O. BOX 437
COLOMA CA
95613
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-7252
  • Fax:
Mailing address:
  • Phone: 530-626-7252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number03042343
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: