Provider Demographics
NPI:1962549014
Name:ROSE, GLENDA RUTH (DC)
Entity type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:RUTH
Last Name:ROSE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MRS
Other - First Name:GLENDA
Other - Middle Name:ROSE
Other - Last Name:BARBA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:435 RIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1205
Mailing Address - Country:US
Mailing Address - Phone:716-754-9039
Mailing Address - Fax:716-754-9064
Practice Address - Street 1:435 RIDGE ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092-1205
Practice Address - Country:US
Practice Address - Phone:716-754-9039
Practice Address - Fax:716-754-9064
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX002901111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC02901-9OtherWORKERS COMPENSATION
NY085811Medicare ID - Type UnspecifiedPROVIDER NUMBER