Provider Demographics
NPI:1295191211
Name:ROOS, ERIN
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:ROOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-6535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12250 EL CAMINO REAL
Practice Address - Street 2:190
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130
Practice Address - Country:US
Practice Address - Phone:858-793-1460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43450225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB252082Medicare PIN
CAW17215AMedicare PIN
CACB252084Medicare PIN
CAW17215Medicare PIN