Healthcare Provider Details

I. General information

NPI: 1366361651
Provider Name (Legal Business Name): MICHAEL JOHN ROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 BUSHNELL RD
LISBON CT
06351-2910
US

IV. Provider business mailing address

7 BUSHNELL RD
LISBON CT
06351-2910
US

V. Phone/Fax

Practice location:
  • Phone: 959-929-5085
  • Fax:
Mailing address:
  • Phone: 959-929-5085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146M00000X
TaxonomyIntermediate Emergency Medical Technician
License Number71.001728
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: