=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700011145
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENDA N ROGERS LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/28/2009
-----------------------------------------------------
Last Update Date | 04/29/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 MEDICAL CENTER DR CARDIOLOGY SUITE
-----------------------------------------------------
City | POWDERLY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42367-5463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-338-9830
-----------------------------------------------------
Fax | 270-338-6874
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 97
-----------------------------------------------------
City | POWDERLY
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42367-0097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | KY-0836
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------