Provider Demographics
NPI:1255651113
Name:ROSAASEN PHYSICAL MEDICINE INC
Entity Type:Organization
Organization Name:ROSAASEN PHYSICAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:R
Authorized Official - Last Name:GLADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:805-520-2929
Mailing Address - Street 1:2780 TAPO CANYON RD
Mailing Address - Street 2:SUITE A3
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-6840
Mailing Address - Country:US
Mailing Address - Phone:805-520-2929
Mailing Address - Fax:805-520-2948
Practice Address - Street 1:2780 TAPO CANYON RD
Practice Address - Street 2:SUITE A3
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-6840
Practice Address - Country:US
Practice Address - Phone:805-520-2929
Practice Address - Fax:805-520-2948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25341111N00000X
CA27915111N00000X
CAA85781208D00000X, 208D00000X, 208D00000X
CA22683363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6601920001Medicare NSC