MEDICARE: LYLE ROSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	29177	OR

General Provider Information

NPI Number	:	1801745906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYLE ROSE

Provider Business Mailing Address
First Line	:	7409 N KNOWLES AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97217-1231
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2003 NE HOLMAN ST
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-5478
Country	:	US
Telephone Number	:	504-503-2975
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2026
Last Update Date	:	01/22/2026

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Directions to “ LYLE ROSE ” Practice Location

Language	Start Address	Practice Location

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