Provider Demographics
NPI:1639215148
Name:ROSE, DAVID W (DC CHIROPRACTOR)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:W
Last Name:ROSE
Suffix:
Gender:M
Credentials:DC CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 MAGNOLIA AVE
Mailing Address - Street 2:#1
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939
Mailing Address - Country:US
Mailing Address - Phone:415-924-2118
Mailing Address - Fax:415-924-5564
Practice Address - Street 1:641 MAGNOLIA AVE
Practice Address - Street 2:#1
Practice Address - City:LARKSPUR
Practice Address - State:CA
Practice Address - Zip Code:94939
Practice Address - Country:US
Practice Address - Phone:415-924-2118
Practice Address - Fax:415-924-5564
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18939111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0891420Medicare ID - Type Unspecified