Provider Demographics
NPI:1306916424
Name:ROSENTHAL, BRIAN A (LAC)
Entity type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:A
Last Name:ROSENTHAL
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-6712
Mailing Address - Country:US
Mailing Address - Phone:541-773-9877
Mailing Address - Fax:541-773-5725
Practice Address - Street 1:714 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6712
Practice Address - Country:US
Practice Address - Phone:541-773-9877
Practice Address - Fax:541-773-5725
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00333171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150696Medicaid