Healthcare Provider Details

I. General information

NPI: 1720164593
Provider Name (Legal Business Name): ROGER L. SPRAGUE CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3956 KINGS CROSSROADS RD
GREENVILLE NC
27834-7323
US

IV. Provider business mailing address

3956 KINGS CROSSROADS RD
GREENVILLE NC
27834-7323
US

V. Phone/Fax

Practice location:
  • Phone: 501-580-4548
  • Fax:
Mailing address:
  • Phone: 501-580-4548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number291022
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: