Provider Demographics
NPI:1023368305
Name:ROGERS, BRIAN WILLIAM (RN LPN)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:WILLIAM
Last Name:ROGERS
Suffix:
Gender:M
Credentials:RN LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 HUBAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-3738
Mailing Address - Country:US
Mailing Address - Phone:616-889-3442
Mailing Address - Fax:
Practice Address - Street 1:712 NORTH CENTER DR. NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49544
Practice Address - Country:US
Practice Address - Phone:616-784-1454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-14
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704218039163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse