Provider Demographics
NPI:1356096986
Name:ROSE CITY THERAPEUTICS LLC
Entity Type:Organization
Organization Name:ROSE CITY THERAPEUTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NEUROCOUNSELOR AND BUSINESS OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MARKOVICS
Authorized Official - Suffix:
Authorized Official - Credentials:NCC, PHD
Authorized Official - Phone:971-224-4089
Mailing Address - Street 1:7770 SW MOHAWK ST BLDG F
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9191
Mailing Address - Country:US
Mailing Address - Phone:971-224-4089
Mailing Address - Fax:
Practice Address - Street 1:7770 SW MOHAWK ST BLDG F
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9191
Practice Address - Country:US
Practice Address - Phone:971-224-4089
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1508457904Medicaid