Provider Demographics
NPI:1851521231
Name:MYSTICAL ROSE OBSTETRICS AND GYNECOLOGY
Entity Type:Organization
Organization Name:MYSTICAL ROSE OBSTETRICS AND GYNECOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHILO
Authorized Official - Middle Name:
Authorized Official - Last Name:STIGEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-318-4798
Mailing Address - Street 1:577 E ELDER ST STE K
Mailing Address - Street 2:
Mailing Address - City:FALLBROOK
Mailing Address - State:CA
Mailing Address - Zip Code:92028-3079
Mailing Address - Country:US
Mailing Address - Phone:760-983-4024
Mailing Address - Fax:760-723-9010
Practice Address - Street 1:577 E ELDER ST STE K
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3079
Practice Address - Country:US
Practice Address - Phone:760-983-4024
Practice Address - Fax:760-723-9010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty