Provider Demographics
NPI:1760762587
Name:ROSE, KEVIN (DC)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
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 1:2635 CAMINO DEL RIO S STE 301
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3729
Mailing Address - Country:US
Mailing Address - Phone:619-818-4306
Mailing Address - Fax:619-828-1030
Practice Address - Street 1:2635 CAMINO DEL RIO S STE 301
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3729
Practice Address - Country:US
Practice Address - Phone:619-818-4306
Practice Address - Fax:619-828-1030
Is Sole Proprietor?:No
Enumeration Date:2011-08-24
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31968111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GE895AMedicare UPIN