Provider Demographics
NPI:1598159576
Name:ROSE WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:ROSE WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-775-2180
Mailing Address - Street 1:910 OLD CAMP RD
Mailing Address - Street 2:SUITE 92
Mailing Address - City:THE VILLAGES
Mailing Address - State:FL
Mailing Address - Zip Code:32162-5604
Mailing Address - Country:US
Mailing Address - Phone:386-334-0133
Mailing Address - Fax:
Practice Address - Street 1:910 OLD CAMP RD
Practice Address - Street 2:SUITE 92
Practice Address - City:THE VILLAGES
Practice Address - State:FL
Practice Address - Zip Code:32162-5604
Practice Address - Country:US
Practice Address - Phone:352-775-2180
Practice Address - Fax:352-775-2930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11031111N00000X
FL053562208D00000X
FL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009SSOtherBCBS
FL009SSOtherBCBS