Provider Demographics
NPI:1558387522
Name:ROSE, SAMUEL B (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:B
Last Name:ROSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:1179 N MCDOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-6559
Mailing Address - Country:US
Mailing Address - Phone:707-559-7500
Mailing Address - Fax:707-559-7620
Practice Address - Street 1:1188 YULUPA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-7253
Practice Address - Country:US
Practice Address - Phone:707-495-7703
Practice Address - Fax:707-978-2952
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2019-09-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA32103111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U73783Medicare UPIN