Provider Demographics
NPI:1053645648
Name:MARK A ROSA
Entity Type:Organization
Organization Name:MARK A ROSA
Other - Org Name:MARK ROSA OD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBI
Authorized Official - Middle Name:
Authorized Official - Last Name:NEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-681-4125
Mailing Address - Street 1:7710 LIMONITE AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-5342
Mailing Address - Country:US
Mailing Address - Phone:951-681-4125
Mailing Address - Fax:951-361-4595
Practice Address - Street 1:7710 LIMONITE AVE STE 101
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-5342
Practice Address - Country:US
Practice Address - Phone:951-681-4125
Practice Address - Fax:951-361-4595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-29
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8575T332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053645648Medicare NSC