Healthcare Provider Details

I. General information

NPI: 1619035326
Provider Name (Legal Business Name): ROGER CRAIG GAGE DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 09/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 DEWITT LOOP RIVER PALVILON 2ND FLOOR R2.102
FORT BELVOIOR VA
22060-0003
US

IV. Provider business mailing address

7530 REPUBLIC CT APT 301
ALEXANDRIA VA
22306-7530
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-1337
  • Fax:
Mailing address:
  • Phone: 605-360-4945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0100X
TaxonomyOccupational Health Chiropractor
License Number665
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: