Healthcare Provider Details

I. General information

NPI: 1912517806
Provider Name (Legal Business Name): MRS. GLORIOSE SAKUBU-ROTHROCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2020
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 N FIFE ST
TACOMA WA
98406-7509
US

IV. Provider business mailing address

1703 N FIFE ST
TACOMA WA
98406-7509
US

V. Phone/Fax

Practice location:
  • Phone: 253-973-3460
  • Fax:
Mailing address:
  • Phone: 253-973-3460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: