Healthcare Provider Details

I. General information

NPI: 1346499936
Provider Name (Legal Business Name): MICHAEL RENE ROGERS LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2008
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 W 25TH AVE
COVINGTON LA
70433-1321
US

IV. Provider business mailing address

1031 W 25TH AVE
COVINGTON LA
70433-1321
US

V. Phone/Fax

Practice location:
  • Phone: 985-789-0983
  • Fax:
Mailing address:
  • Phone: 985-789-0983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberLA 2731
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License Number10800
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: