Healthcare Provider Details

I. General information

NPI: 1407096381
Provider Name (Legal Business Name): PHILIP ROGGOW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2009
Last Update Date: 11/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2215 N BROADWAY SUITE 200
SANTA ANA CA
92706-2663
US

IV. Provider business mailing address

2215 N BROADWAY SUITE 200
SANTA ANA CA
92706-2663
US

V. Phone/Fax

Practice location:
  • Phone: 714-721-6400
  • Fax: 714-221-6401
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: