Provider Demographics
NPI:1184672255
Name:ROOS, MARK EDWARD (LMT)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:EDWARD
Last Name:ROOS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Mailing Address - Street 1:841 GRAVEL RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-1717
Mailing Address - Country:US
Mailing Address - Phone:585-671-0449
Mailing Address - Fax:
Practice Address - Street 1:6605 PITTSFORD PALMYRA RD
Practice Address - Street 2:SUITE E-9
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-3407
Practice Address - Country:US
Practice Address - Phone:585-223-0644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007327225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1758733GGOtherPREFERRED CARE