Provider Demographics
NPI:1124179585
Name:SANDRAGORSIAN, ROSA P (LAC)
Entity Type:Individual
Prefix:MS
First Name:ROSA
Middle Name:P
Last Name:SANDRAGORSIAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1834 W BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1348
Mailing Address - Country:US
Mailing Address - Phone:818-429-2576
Mailing Address - Fax:
Practice Address - Street 1:1834 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1348
Practice Address - Country:US
Practice Address - Phone:818-429-2576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 10962171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist