Healthcare Provider Details

I. General information

NPI: 1245636190
Provider Name (Legal Business Name): JAMES ROSE AGCNS-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2014
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1924 FOREST RIDGE DR
BEDFORD TX
76021-8228
US

IV. Provider business mailing address

409 LARK ST
LEANDER TX
78641-1750
US

V. Phone/Fax

Practice location:
  • Phone: 817-545-4550
  • Fax: 817-571-0804
Mailing address:
  • Phone: 512-468-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberAP126386
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberAP126386
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: