Healthcare Provider Details

I. General information

NPI: 1417506247
Provider Name (Legal Business Name): VICKIE LYNN ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15405 LANSDOWNE RD STE C
TUSTIN CA
92782-0201
US

IV. Provider business mailing address

15327 WOODRUFF PL APT 229
BELLFLOWER CA
90706-4052
US

V. Phone/Fax

Practice location:
  • Phone: 714-258-7710
  • Fax:
Mailing address:
  • Phone: 562-608-5505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: