Provider Demographics
NPI:1275232886
Name:ROSE, ELWYN STANFORD
Entity Type:Individual
Prefix:MR
First Name:ELWYN
Middle Name:STANFORD
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 1:2503 ALAMOCITOS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76549-6101
Mailing Address - Country:US
Mailing Address - Phone:912-398-7380
Mailing Address - Fax:
Practice Address - Street 1:2503 ALAMOCITOS CREEK DR
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6101
Practice Address - Country:US
Practice Address - Phone:912-398-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-02
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Yes172A00000XOther Service ProvidersDriver