Provider Demographics
NPI:1629071030
Name:ROSE, ROBERT JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAMES
Last Name:ROSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 E HUALAPAI MOUNTAIN RD
Mailing Address - Street 2:STE B
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-8324
Mailing Address - Country:US
Mailing Address - Phone:928-718-0808
Mailing Address - Fax:
Practice Address - Street 1:2215 E HUALAPAI MOUNTAIN RD
Practice Address - Street 2:STE B
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86401-8324
Practice Address - Country:US
Practice Address - Phone:928-718-0808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5047111N00000X
CA22143111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0241740OtherBLUE CROSS/BLUE SHIELD AZ
AZZDC5047Medicare ID - Type Unspecified
AZAZ0241740OtherBLUE CROSS/BLUE SHIELD AZ