Provider Demographics
NPI:1871783464
Name:ROSA, LAGENA (DC)
Entity type:Individual
Prefix:DR
First Name:LAGENA
Middle Name:
Last Name:ROSA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 W PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-4506
Mailing Address - Country:US
Mailing Address - Phone:870-424-3611
Mailing Address - Fax:870-424-3761
Practice Address - Street 1:424 W PAUL AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-4506
Practice Address - Country:US
Practice Address - Phone:870-424-3611
Practice Address - Fax:870-424-3761
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A561Medicare PIN