Healthcare Provider Details

I. General information

NPI: 1518902881
Provider Name (Legal Business Name): ROSE OSTEOPATHIC CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 02/10/2024
Certification Date: 02/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54699 HILLSIDE RD
ST IGNATIUS MT
59865-8915
US

IV. Provider business mailing address

54699 HILLSIDE RD
ST IGNATIUS MT
59865-8915
US

V. Phone/Fax

Practice location:
  • Phone: 406-745-0845
  • Fax: 833-918-2217
Mailing address:
  • Phone: 406-745-0845
  • Fax: 406-204-3238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number02001899
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberMED-PHYS-LIC-53457
License Number StateMT

VIII. Authorized Official

Name: DHARMA ROSE
Title or Position: PRESIDENT
Credential: D.O.
Phone: 406-745-0845