Healthcare Provider Details

I. General information

NPI: 1063944247
Provider Name (Legal Business Name): DAVID ROSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 08/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 MERCHANTS DR
HILLSBORO MO
63050-5212
US

IV. Provider business mailing address

304 N 3RD ST PO BOX 920
DE SOTO MO
63020-1505
US

V. Phone/Fax

Practice location:
  • Phone: 636-789-2686
  • Fax:
Mailing address:
  • Phone: 636-209-8720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: