Provider Demographics
NPI:1750574422
Name:LAGENA L ROSA DC PA
Entity type:Organization
Organization Name:LAGENA L ROSA DC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LAGENA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-424-3611
Mailing Address - Street 1:230 HWY 5 NORTH
Mailing Address - Street 2:SUITE 10
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2416
Mailing Address - Country:US
Mailing Address - Phone:870-424-3611
Mailing Address - Fax:870-424-3761
Practice Address - Street 1:230 HWY 5 NORTH
Practice Address - Street 2:SUITE 10
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2416
Practice Address - Country:US
Practice Address - Phone:870-424-3611
Practice Address - Fax:870-424-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty