Provider Demographics
NPI:1356894653
Name:ROSE, BENJAMIN (DPT)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:ROSE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CREDIT UNION WAY FL 3
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:MA
Mailing Address - Zip Code:02368-4633
Mailing Address - Country:US
Mailing Address - Phone:781-961-3370
Mailing Address - Fax:781-961-1291
Practice Address - Street 1:540 GALLIVAN BLVD FL 2ND
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5400
Practice Address - Country:US
Practice Address - Phone:617-282-8080
Practice Address - Fax:617-282-9988
Is Sole Proprietor?:No
Enumeration Date:2016-08-03
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22442225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist