Healthcare Provider Details

I. General information

NPI: 1710391768
Provider Name (Legal Business Name): ROSE THUNDER CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2014
Last Update Date: 01/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CENTRAL AVE E STE B
SAINT MICHAEL MN
55376-9511
US

IV. Provider business mailing address

2520 LANDER AVE NE
SAINT MICHAEL MN
55376-9398
US

V. Phone/Fax

Practice location:
  • Phone: 612-867-1135
  • Fax:
Mailing address:
  • Phone: 612-867-1335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: