Healthcare Provider Details

I. General information

NPI: 1083037428
Provider Name (Legal Business Name): PHILIP GREGORY RODGER D.C., B.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

317 VICKI TOWERS DR
ST AUGUSTINE FL
32092-1757
US

IV. Provider business mailing address

317 VICKI TOWERS DR
ST AUGUSTINE FL
32092-1757
US

V. Phone/Fax

Practice location:
  • Phone: 904-428-0766
  • Fax:
Mailing address:
  • Phone: 904-428-0766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHR.0007086
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH 11946
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: