Provider Demographics
NPI:1003855669
Name:HARRIS, ROGER JACK JR (DC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:JACK
Last Name:HARRIS
Suffix:JR
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 1:6430 US ROUTE 60 E
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1240
Mailing Address - Country:US
Mailing Address - Phone:304-736-4111
Mailing Address - Fax:304-736-0334
Practice Address - Street 1:6430 US ROUTE 60 E
Practice Address - Street 2:
Practice Address - City:BARBOURSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25504-1240
Practice Address - Country:US
Practice Address - Phone:304-736-4111
Practice Address - Fax:304-736-0334
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV722111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7600098000Medicaid
WV7600098000Medicaid
WV0896002Medicare ID - Type UnspecifiedMEDICARE NUMBER