Provider Demographics
NPI:1578000733
Name:MEMORY REHABILITATION MEDICAL GROUP INC
Entity Type:Organization
Organization Name:MEMORY REHABILITATION MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-345-8427
Mailing Address - Street 1:9461 FLOWER STREET
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90760-5705
Mailing Address - Country:US
Mailing Address - Phone:714-345-8427
Mailing Address - Fax:
Practice Address - Street 1:9461 FLOWER STREET
Practice Address - Street 2:
Practice Address - City:BELLFLOWER
Practice Address - State:CA
Practice Address - Zip Code:90760-5705
Practice Address - Country:US
Practice Address - Phone:714-345-8427
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-26
Last Update Date:2017-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA044506207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty