Healthcare Provider Details

I. General information

NPI: 1558488148
Provider Name (Legal Business Name): MELISSA R ROSE PT, DPT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 03/08/2024
Certification Date: 03/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 N AVIATION BLVD
EL SEGUNDO CA
90245-2808
US

IV. Provider business mailing address

483 N AVIATION BLVD
EL SEGUNDO CA
90245-2808
US

V. Phone/Fax

Practice location:
  • Phone: 310-653-5868
  • Fax:
Mailing address:
  • Phone: 310-653-5868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1173293
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number011516
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1173293
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: