1518902881 NPI number — ROSE OSTEOPATHIC CLINIC, INC.

Table of content: (NPI 1518902881)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518902881 NPI number — ROSE OSTEOPATHIC CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE OSTEOPATHIC CLINIC, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DEFRESE OSTEOPATHIC CLINIC, INC.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518902881
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54699 HILLSIDE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ST IGNATIUS
Provider Business Mailing Address State Name:
MT
Provider Business Mailing Address Postal Code:
59865-8915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-745-0845
Provider Business Mailing Address Fax Number:
406-204-3238

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
54699 HILLSIDE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST IGNATIUS
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59865-8915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
406-745-0845
Provider Business Practice Location Address Fax Number:
833-918-2217
Provider Enumeration Date:
06/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROSE
Authorized Official First Name:
DHARMA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
406-745-0845

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X , with the licence number:  02001899 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X , with the licence number: MED-PHYS-LIC-53457 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1518902881 . This is a "BCBS MONTANA PROVIDER IDENTIFIER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 200977140A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1518902881 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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