Provider Demographics
NPI:1700250198
Name:ROGERS, TIMOTHY CARL
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:CARL
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 1:51 INDUSTRIAL PARKWAY
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:51 INDUSTRIAL PARKWAY
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093
Practice Address - Country:US
Practice Address - Phone:530-623-1204
Practice Address - Fax:530-623-1237
Is Sole Proprietor?:No
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAF4785167OtherDRIVER'S LICENSE