Provider Demographics
NPI:1518902881
Name:ROSE OSTEOPATHIC CLINIC, INC.
Entity Type:Organization
Organization Name:ROSE OSTEOPATHIC CLINIC, INC.
Other - Org Name:DEFRESE OSTEOPATHIC CLINIC, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DHARMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:406-745-0845
Mailing Address - Street 1:54699 HILLSIDE RD
Mailing Address - Street 2:
Mailing Address - City:ST IGNATIUS
Mailing Address - State:MT
Mailing Address - Zip Code:59865-8915
Mailing Address - Country:US
Mailing Address - Phone:406-745-0845
Mailing Address - Fax:406-204-3238
Practice Address - Street 1:54699 HILLSIDE RD
Practice Address - Street 2:
Practice Address - City:ST IGNATIUS
Practice Address - State:MT
Practice Address - Zip Code:59865-8915
Practice Address - Country:US
Practice Address - Phone:406-745-0845
Practice Address - Fax:833-918-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001899261QH0100X
MTMED-PHYS-LIC-53457261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
1518902881OtherBCBS MONTANA PROVIDER IDENTIFIER
IN200977140AMedicaid
MT1518902881Medicaid