Provider Demographics
NPI:1639400955
Name:DE MESA, KAREN ROSCELA MANUBAG (RPT)
Entity Type:Individual
Prefix:MRS
First Name:KAREN ROSCELA
Middle Name:MANUBAG
Last Name:DE MESA
Suffix:
Gender:F
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6020 W SAMPLE RD
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33067-3261
Mailing Address - Country:US
Mailing Address - Phone:954-752-6188
Mailing Address - Fax:
Practice Address - Street 1:6020 W SAMPLE RD
Practice Address - Street 2:APT 101
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33067-3261
Practice Address - Country:US
Practice Address - Phone:954-752-6188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18925261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain