Provider Demographics
NPI:1962170704
Name:ROSE, JOHNNY OTIS JR
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:OTIS
Last Name:ROSE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 DOVER RD
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-5780
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:818 DOVER RD
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-5780
Practice Address - Country:US
Practice Address - Phone:850-321-7524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-04
Last Update Date:2021-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2278C0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278C0205XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedCritical Care