Provider Demographics
NPI:1851855035
Name:PERCIVAL, ROSEMUNDE MARCIA CHRISTINE (LLC OWNER)
Entity Type:Individual
Prefix:MRS
First Name:ROSEMUNDE
Middle Name:MARCIA CHRISTINE
Last Name:PERCIVAL
Suffix:
Gender:F
Credentials:LLC OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 COLES MILL RD APT 101
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-1079
Mailing Address - Country:US
Mailing Address - Phone:856-203-4223
Mailing Address - Fax:
Practice Address - Street 1:555 COLES MILL RD APT 101
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-1079
Practice Address - Country:US
Practice Address - Phone:856-203-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ47-5116681Medicaid