=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982092615
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. CHRISTINE ROLLE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2015
-----------------------------------------------------
Last Update Date | 01/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4121 CORNELIA WAY
-----------------------------------------------------
City | NORTH HIGHLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95660-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-914-3095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4121 CORNELIA WAY
-----------------------------------------------------
City | NORTH HIGHLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95660-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-914-3095
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | 738600
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------