Healthcare Provider Details

I. General information

NPI: 1053808162
Provider Name (Legal Business Name): JOHN ST. ROSE JR. ND
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 10/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 E UNIVERSITY DR STE 10
MESA AZ
85203-8046
US

IV. Provider business mailing address

1050 E UNIVERSITY DR STE 10
MESA AZ
85203-8046
US

V. Phone/Fax

Practice location:
  • Phone: 480-712-7099
  • Fax:
Mailing address:
  • Phone: 480-712-7099
  • Fax: 480-712-7099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number870274
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number171624
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: