Provider Demographics
NPI:1437392636
Name:ROSE, LARRY JACOB
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:JACOB
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:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:RED BLUFF
Mailing Address - State:CA
Mailing Address - Zip Code:96080-0400
Mailing Address - Country:US
Mailing Address - Phone:530-527-5637
Mailing Address - Fax:530-527-0249
Practice Address - Street 1:1860 WALNUT ST
Practice Address - Street 2:SUITE A
Practice Address - City:RED BLUFF
Practice Address - State:CA
Practice Address - Zip Code:96080-3611
Practice Address - Country:US
Practice Address - Phone:530-527-5637
Practice Address - Fax:530-527-0249
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide