Healthcare Provider Details

I. General information

NPI: 1982168977
Provider Name (Legal Business Name): NICHOLAS DAVID ROSEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2019
Last Update Date: 01/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 COFFEE RD
MODESTO CA
95355-4915
US

IV. Provider business mailing address

409 COFFEE RD
MODESTO CA
95355-4915
US

V. Phone/Fax

Practice location:
  • Phone: 209-527-5346
  • Fax: 209-527-0124
Mailing address:
  • Phone: 209-527-5346
  • Fax: 209-527-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: