Healthcare Provider Details

I. General information

NPI: 1235326075
Provider Name (Legal Business Name): DIANA ROZE LAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 12/14/2025
Certification Date: 12/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

617 FRANKLIN AVE UNIT 4
BERLIN MD
21811-1358
US

IV. Provider business mailing address

9-09 ELAINE TER
FAIR LAWN NJ
07410-5714
US

V. Phone/Fax

Practice location:
  • Phone: 201-294-2970
  • Fax:
Mailing address:
  • Phone: 201-294-2970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number025717
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberU03251
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: