Provider Demographics
NPI:1386972610
Name:ROGERS, CHARLES
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:ROGERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 LETTON DR
Mailing Address - Street 2:
Mailing Address - City:RATON
Mailing Address - State:NM
Mailing Address - Zip Code:87740-4366
Mailing Address - Country:US
Mailing Address - Phone:575-445-8568
Mailing Address - Fax:575-445-0540
Practice Address - Street 1:101 LETTON DR
Practice Address - Street 2:
Practice Address - City:RATON
Practice Address - State:NM
Practice Address - Zip Code:87740-4366
Practice Address - Country:US
Practice Address - Phone:575-445-8568
Practice Address - Fax:575-445-0540
Is Sole Proprietor?:No
Enumeration Date:2009-11-24
Last Update Date:2009-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM71525564Medicaid