Healthcare Provider Details

I. General information

NPI: 1639604317
Provider Name (Legal Business Name): KENYA RODGERS CERT HAIRLOSS SPEC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

201 SKYLAND PLZ
SPRING LAKE NC
28390-3429
US

IV. Provider business mailing address

44 CARAWAY CT
CAMERON NC
28326-5048
US

V. Phone/Fax

Practice location:
  • Phone: 910-568-3687
  • Fax:
Mailing address:
  • Phone: 757-329-5363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License NumberC76222
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: