Provider Demographics
NPI:1699865501
Name:RODGES, REGINALD L (DC)
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:L
Last Name:RODGES
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 1:124 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38732-2744
Mailing Address - Country:US
Mailing Address - Phone:662-843-0076
Mailing Address - Fax:662-846-7730
Practice Address - Street 1:124 NORTH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-2744
Practice Address - Country:US
Practice Address - Phone:662-843-0076
Practice Address - Fax:662-846-7730
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0950111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor