Provider Demographics
NPI:1336116458
Name:DUCASSE, ROSE A (DC)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:A
Last Name:DUCASSE
Suffix:
Gender:F
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:PO BOX 540
Mailing Address - Street 2:
Mailing Address - City:GRANTS
Mailing Address - State:NM
Mailing Address - Zip Code:87020-0540
Mailing Address - Country:US
Mailing Address - Phone:505-287-5377
Mailing Address - Fax:505-287-5508
Practice Address - Street 1:601 N 1ST ST
Practice Address - Street 2:SUITE B
Practice Address - City:GRANTS
Practice Address - State:NM
Practice Address - Zip Code:87020-2703
Practice Address - Country:US
Practice Address - Phone:505-287-5377
Practice Address - Fax:505-287-5508
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 8548111N00000X
NM1749111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM15051587Medicaid
NM15051587Medicaid