=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386452704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIRSTEN ROSE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2024
-----------------------------------------------------
Last Update Date | 12/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 MECHANIC FALLS RD STE 4
-----------------------------------------------------
City | OXFORD
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04270-3147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-539-5128
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 376 HALLS POND RD
-----------------------------------------------------
City | SOUTH PARIS
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04281-6031
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-520-8755
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT5165
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------