Provider Demographics
NPI:1013157023
Name:ROSE, SAMANTHA A (LMT)
Entity type:Individual
Prefix:MRS
First Name:SAMANTHA
Middle Name:A
Last Name:ROSE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1722 E MCANDREWS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5580
Mailing Address - Country:US
Mailing Address - Phone:541-778-7889
Mailing Address - Fax:
Practice Address - Street 1:1722 E. MCANDREWS RD.
Practice Address - Street 2:SUITE B
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504
Practice Address - Country:US
Practice Address - Phone:541-778-7889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-03
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13153173C00000X, 225700000X
OR00031783247000000X
OR31783247000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No173C00000XOther Service ProvidersReflexologist
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information