1780857623 NPI number — THOMAS D ROSE DC PC

Table of content: (NPI 1780857623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780857623 NPI number — THOMAS D ROSE DC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THOMAS D ROSE DC PC
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:
Provider Other Organization Name Type Code:
6
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:
1780857623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
489 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHFIELD
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84701-1822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-896-8820
Provider Business Mailing Address Fax Number:
435-896-0334

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
489 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHFIELD
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84701-1822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-896-8820
Provider Business Practice Location Address Fax Number:
435-896-0334
Provider Enumeration Date:
04/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
ROSE
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
D
Authorized Official Title or Position:
DOCTOR/OWNER
Authorized Official Telephone Number:
435-896-8820

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  164775-1202 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1032704 . This is a "AMERICAN SPECIALTY HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 53034192077001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 36360 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 530341920016 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 870395551RO1 . This is a "EDUCATORS MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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