MEDICARE: DR. ROBERT JAMES ROSE D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5047	AZ
2	111N00000X	Chiropractor	22143	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0241740	OTHER	AZ	BLUE CROSS/BLUE SHIELD AZ

General Provider Information

NPI Number	:	1629071030
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT JAMES ROSE D.C.

Provider Business Mailing Address
First Line	:	2215 E HUALAPAI MOUNTAIN RD
Second Line	:	STE B
City	:	KINGMAN
State	:	AZ
Zip	:	86401-8324
Country	:	US
Telephone Number	:	928-718-0808
Fax Number	:

Provider Business Practice Location Address
First Line	:	2215 E HUALAPAI MOUNTAIN RD
Second Line	:	STE B
City	:	KINGMAN
State	:	AZ
Zip	:	86401-8324
Country	:	US
Telephone Number	:	928-718-0808
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	12/27/2007

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