Provider Demographics
NPI:1134291172
Name:ROSE, MELVIN C (DC)
Entity Type:Individual
Prefix:DR
First Name:MELVIN
Middle Name:C
Last Name:ROSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4410 N KNOXVILLE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-6083
Mailing Address - Country:US
Mailing Address - Phone:309-685-8071
Mailing Address - Fax:
Practice Address - Street 1:4410 N KNOXVILLE AVE STE E
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-6083
Practice Address - Country:US
Practice Address - Phone:309-685-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-002925111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
267860Medicare ID - Type Unspecified