Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 175F00000X | Naturopath | 171624 | AZ |
NPI | 1053808162 |
---|---|
Provider Name | Dr. John St. Rose JR. |
First Address | Mesa, AZ 85203-8046 |
Second Address | Mesa, AZ 85203-8046 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2018 |
Last Update Date | 02/10/2019 |