Provider Demographics
NPI:1760103824
Name:MADISON, ROSE
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:MADISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17024 BUTTE CREEK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77090-2329
Mailing Address - Country:US
Mailing Address - Phone:346-978-8586
Mailing Address - Fax:
Practice Address - Street 1:17024 BUTTE CREEK RD STE 204
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77090-2329
Practice Address - Country:US
Practice Address - Phone:346-978-8586
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-07
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9049251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX9049OtherNFA LICENSE