Healthcare Provider Details

I. General information

NPI: 1659821296
Provider Name (Legal Business Name): VIROSA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2016
Last Update Date: 10/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1051 TENNIS LN
TRACY CA
95376-4417
US

IV. Provider business mailing address

1051 TENNIS LN
TRACY CA
95376-4417
US

V. Phone/Fax

Practice location:
  • Phone: 415-812-2955
  • Fax:
Mailing address:
  • Phone: 415-812-2955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number550003672
License Number StateCA

VIII. Authorized Official

Name: ALEX RUDAKOV
Title or Position: PRESIDENT
Credential:
Phone: 415-812-2955