Provider Demographics
NPI:1336164466
Name:ROSE, THOMAS D (DC)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
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:PO BOX 146
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701-0146
Mailing Address - Country:US
Mailing Address - Phone:435-896-8820
Mailing Address - Fax:435-896-0334
Practice Address - Street 1:489 N MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-1822
Practice Address - Country:US
Practice Address - Phone:435-896-8820
Practice Address - Fax:435-896-0334
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT164775-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTALTIUSOther58303
0005935097OtherAETNA
UT36360OtherDMBA
UT22780OtherPEHP
UT870395551RO1OtherEMIA
UT870395551RO1OtherEMIA