Healthcare Provider Details

I. General information

NPI: 1689244865
Provider Name (Legal Business Name): MRS. REGINA RAE ROGERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REGINA RAE DEPUE

II. Dates (important events)

Enumeration Date: 06/29/2021
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12625 HESPERIA RD
VICTORVILLE CA
92395-7720
US

IV. Provider business mailing address

12625 HESPERIA RD
VICTORVILLE CA
92395-7720
US

V. Phone/Fax

Practice location:
  • Phone: 760-995-8300
  • Fax: 760-995-2356
Mailing address:
  • Phone: 760-995-8300
  • Fax: 760-995-2356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number139101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: