Healthcare Provider Details

I. General information

NPI: 1265727457
Provider Name (Legal Business Name): COURTNEY E ROSE D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 NACOGDOCHES ST SUITE 275
JACKSONVILLE TX
75766-2462
US

IV. Provider business mailing address

203 NACOGDOCHES ST SUITE 275
JACKSONVILLE TX
75766-2462
US

V. Phone/Fax

Practice location:
  • Phone: 309-541-5472
  • Fax: 903-541-5470
Mailing address:
  • Phone: 309-541-5472
  • Fax: 903-541-5470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberN9947
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: