Healthcare Provider Details

I. General information

NPI: 1144672767
Provider Name (Legal Business Name): BETHANY R. ROSE AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9109 STONY POINT DR
RICHMOND VA
23235-1979
US

IV. Provider business mailing address

7601 FOREST AVE STE 331
RICHMOND VA
23229-4933
US

V. Phone/Fax

Practice location:
  • Phone: 804-828-0431
  • Fax: 804-628-0950
Mailing address:
  • Phone: 804-739-0031
  • Fax: 804-594-8822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2102002929
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: