Provider Demographics
NPI:1053808162
Name:ST. ROSE, JOHN JR (ND)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:ST. ROSE
Suffix:JR
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 E UNIVERSITY DR STE 10
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-8046
Mailing Address - Country:US
Mailing Address - Phone:480-712-7099
Mailing Address - Fax:480-712-7099
Practice Address - Street 1:1050 E UNIVERSITY DR STE 10
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-8046
Practice Address - Country:US
Practice Address - Phone:480-712-7099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-16
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL870274133VN1005X
AZ171624175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal