Healthcare Provider Details

I. General information

NPI: 1053096941
Provider Name (Legal Business Name): CODY ROVELLA L.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 SUTTER STREET SUITE 908
SAN FRANCISCO CA
94102
US

IV. Provider business mailing address

900 BUSH STREET SUITE 215
SAN FRANCISCO CA
94109
US

V. Phone/Fax

Practice location:
  • Phone: 415-470-0140
  • Fax: 415-287-6652
Mailing address:
  • Phone: 415-470-0140
  • Fax: 415-287-6652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberL9814
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: