Provider Demographics
NPI:1376592014
Name:ROSEVILLE ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:ROSEVILLE ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-781-5263
Mailing Address - Street 1:4 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE #210
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-2815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE #210
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-2815
Practice Address - Country:US
Practice Address - Phone:916-773-8780
Practice Address - Fax:916-773-8793
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-09
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA030000786261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31753ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER