Provider Demographics
NPI:1366131070
Name:ROGERS, WILLIAM JORDAN (DC)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JORDAN
Last Name:ROGERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1151 ROBERT M GRISSOM PKWY
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5664
Mailing Address - Country:US
Mailing Address - Phone:843-839-5588
Mailing Address - Fax:843-839-5591
Practice Address - Street 1:1151 ROBERT M GRISSOM PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5664
Practice Address - Country:US
Practice Address - Phone:843-839-5588
Practice Address - Fax:843-839-5591
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5628111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH4936Medicaid