Provider Demographics
NPI:1124400361
Name:ST ROSE HEALTH CENTER INC
Entity Type:Organization
Organization Name:ST ROSE HEALTH CENTER INC
Other - Org Name:ST. ROSE CONVENIENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXEC DIRECTOR PPA
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-623-2185
Mailing Address - Street 1:3515 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-3633
Mailing Address - Country:US
Mailing Address - Phone:620-786-6115
Mailing Address - Fax:620-786-6262
Practice Address - Street 1:3515 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GREAT BEND
Practice Address - State:KS
Practice Address - Zip Code:67530-3633
Practice Address - Country:US
Practice Address - Phone:620-792-2511
Practice Address - Fax:620-792-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty