Provider Demographics
NPI:1083347884
Name:ROSE, ZACHARY C
Entity Type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:C
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 1:400 E CENTRAL AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-4019
Mailing Address - Country:US
Mailing Address - Phone:701-838-1812
Mailing Address - Fax:
Practice Address - Street 1:205 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3934
Practice Address - Country:US
Practice Address - Phone:701-838-1812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-08
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator