Provider Demographics
NPI:1053818674
Name:ROSE, KEITH
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:
Last Name:ROSE
Suffix:
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 1:1286 CALLEN ST
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-3002
Mailing Address - Country:US
Mailing Address - Phone:707-447-8982
Mailing Address - Fax:
Practice Address - Street 1:1286 CALLEN ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3002
Practice Address - Country:US
Practice Address - Phone:707-447-8982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
911861042Other911861042