Healthcare Provider Details

I. General information

NPI: 1558387522
Provider Name (Legal Business Name): SAMUEL B ROSE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1188 YULUPA AVE
SANTA ROSA CA
95405-7253
US

IV. Provider business mailing address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

V. Phone/Fax

Practice location:
  • Phone: 707-495-7703
  • Fax: 707-978-2952
Mailing address:
  • Phone: 707-559-7500
  • Fax: 707-559-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number32103
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: