Provider Demographics
NPI:1508942434
Name:ROSES LIFE CHIROPRACTIC P C
Entity Type:Organization
Organization Name:ROSES LIFE CHIROPRACTIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TONIANN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:973-575-6651
Mailing Address - Street 1:555 PASSAIC AVENUE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006
Mailing Address - Country:US
Mailing Address - Phone:973-575-6651
Mailing Address - Fax:973-575-6260
Practice Address - Street 1:555 PASSAIC AVENUE
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006
Practice Address - Country:US
Practice Address - Phone:973-575-6651
Practice Address - Fax:973-575-6260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC04830111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084236Medicare ID - Type Unspecified