Provider Demographics
NPI:1104952654
Name:ROSEMARY TEN BROEK
Entity type:Organization
Organization Name:ROSEMARY TEN BROEK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:TEN BROEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-567-3522
Mailing Address - Street 1:34 W PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89015-7306
Mailing Address - Country:US
Mailing Address - Phone:702-567-3522
Mailing Address - Fax:702-567-8022
Practice Address - Street 1:34 W PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7306
Practice Address - Country:US
Practice Address - Phone:702-567-3522
Practice Address - Fax:702-567-8022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003302437Medicaid
NV0260560001Medicare ID - Type Unspecified