Provider Demographics
NPI:1134348675
Name:ROSSELLO FAMILY CHIROPRACTIC, PA
Entity type:Organization
Organization Name:ROSSELLO FAMILY CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:ROSSELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:301-464-9400
Mailing Address - Street 1:4000 MITCHELLVILLE RD
Mailing Address - Street 2:SUITE B122
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-3104
Mailing Address - Country:US
Mailing Address - Phone:301-464-9400
Mailing Address - Fax:
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:SUITE B122
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-3104
Practice Address - Country:US
Practice Address - Phone:301-464-9400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS01133111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJ5880001OtherCAREFIRST BCBS DC PROV #
MD876235OtherMAILHANDLERS PROV #
MD452AOtherMD CAREFIRST PROV #
MDG01954Medicare ID - Type Unspecified
MD452AOtherMD CAREFIRST PROV #