Provider Demographics
NPI:1417605106
Name:GOODMAN, ROSE (LAC)
Entity type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:GOODMAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:ROSE
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAC
Mailing Address - Street 1:20529 MEDLEY LN
Mailing Address - Street 2:
Mailing Address - City:TOPANGA
Mailing Address - State:CA
Mailing Address - Zip Code:90290-3363
Mailing Address - Country:US
Mailing Address - Phone:805-452-1287
Mailing Address - Fax:
Practice Address - Street 1:20529 MEDLEY LN
Practice Address - Street 2:
Practice Address - City:TOPANGA
Practice Address - State:CA
Practice Address - Zip Code:90290-3363
Practice Address - Country:US
Practice Address - Phone:805-452-1287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-12
Last Update Date:2022-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16382171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist