Provider Demographics
NPI:1023566973
Name:ROSE, TERRACE SR
Entity Type:Individual
Prefix:MR
First Name:TERRACE
Middle Name:
Last Name:ROSE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 SE 24TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73129-1817
Mailing Address - Country:US
Mailing Address - Phone:405-753-7159
Mailing Address - Fax:
Practice Address - Street 1:401 SE 24TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73129-1817
Practice Address - Country:US
Practice Address - Phone:405-753-7159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator