Provider Demographics
NPI:1780987446
Name:ROSE, LARA
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15386
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-0007
Mailing Address - Country:US
Mailing Address - Phone:951-707-8289
Mailing Address - Fax:
Practice Address - Street 1:860 HARRISON AVE
Practice Address - Street 2:9TH FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-4002
Practice Address - Country:US
Practice Address - Phone:617-414-4758
Practice Address - Fax:617-414-6855
Is Sole Proprietor?:No
Enumeration Date:2010-12-17
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program