Healthcare Provider Details

I. General information

NPI: 1033326541
Provider Name (Legal Business Name): ROSE CLINIC A PROFESIONAL MEDICAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 04/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 LOMAS SANTA FE DR B-1
SOLANA BEACH CA
92075-1349
US

IV. Provider business mailing address

530 LOMAS SANTA FE DR B-1
SOLANA BEACH CA
92075-1349
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-8955
  • Fax: 858-755-8959
Mailing address:
  • Phone: 858-755-8955
  • Fax: 858-755-8959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085D0003X
TaxonomyDiagnostic Neuroimaging (Radiology) Physician
License NumberG85456
License Number StateCA

VIII. Authorized Official

Name: JEANNE STRYKER
Title or Position: CEO
Credential: MD
Phone: 858-755-8955