MEDICARE: MRS. KIMBERLY KAY ROGERS RD LD N

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	ND 1278	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LD # ND1278	OTHER	FL	LICENSED
2	RD 713403	OTHER	FL	REGISTRATION

General Provider Information

NPI Number	:	1932100294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY KAY ROGERS RD LD N

Provider Business Mailing Address
First Line	:	290 SUNRISE DR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34945-4125
Country	:	US
Telephone Number	:	772-461-1349
Fax Number	:

Provider Business Practice Location Address
First Line	:	290 SUNRISE DR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34945-4125
Country	:	US
Telephone Number	:	772-461-1349
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/09/2005
Last Update Date	:	12/28/2007

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