Healthcare Provider Details

I. General information

NPI: 1669065918
Provider Name (Legal Business Name): HARLEY ROGERS RD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2720 LOW CT
FAIRFIELD CA
94534-9771
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 707-434-2053
  • Fax:
Mailing address:
  • Phone: 191-670-8803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86069886
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: