Provider Demographics
NPI:1942606108
Name:ROSE, BRANDON LEE (BS DEGREE)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:LEE
Last Name:ROSE
Suffix:
Gender:M
Credentials:BS DEGREE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9207 MAMMATH PEAK CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95212-3212
Mailing Address - Country:US
Mailing Address - Phone:209-623-7456
Mailing Address - Fax:209-594-1872
Practice Address - Street 1:9207 MAMMATH PEAK CIR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95212-3212
Practice Address - Country:US
Practice Address - Phone:209-623-7456
Practice Address - Fax:209-594-1872
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-14
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA397002695310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility