Healthcare Provider Details

I. General information

NPI: 1811433253
Provider Name (Legal Business Name): ROSE FAGAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9285 HEPBURN ST
HIGHLANDS RANCH CO
80129-2262
US

IV. Provider business mailing address

9795 FOXHILL CIR
HIGHLANDS RANCH CO
80129-4304
US

V. Phone/Fax

Practice location:
  • Phone: 303-636-3321
  • Fax:
Mailing address:
  • Phone: 303-470-3473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0002468
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: