Provider Demographics
NPI:1255606943
Name:ROSEN, RICHARD STUART (LAC)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:STUART
Last Name:ROSEN
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1713
Mailing Address - Street 2:
Mailing Address - City:FORESTVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95436-1713
Mailing Address - Country:US
Mailing Address - Phone:707-887-1165
Mailing Address - Fax:707-887-2184
Practice Address - Street 1:6544 FRONT ST
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:CA
Practice Address - Zip Code:95436-9686
Practice Address - Country:US
Practice Address - Phone:707-887-1165
Practice Address - Fax:707-887-2184
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC6678171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist