Healthcare Provider Details

I. General information

NPI: 1760651046
Provider Name (Legal Business Name): JERRY D ROGERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2008
Last Update Date: 03/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 JI BELL LN
SAVANNAH TN
38372-5110
US

IV. Provider business mailing address

PO BOX 638
SAVANNAH TN
38372-0638
US

V. Phone/Fax

Practice location:
  • Phone: 731-925-4902
  • Fax: 731-925-4445
Mailing address:
  • Phone: 731-925-4902
  • Fax: 731-925-4445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: JERRY D ROGERS
Title or Position: OWNER
Credential:
Phone: 731-925-4902