Provider Demographics
NPI:1164074688
Name:ROGERS, BLAINE M
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:M
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 1:6200 SYLVAN LN
Mailing Address - Street 2:
Mailing Address - City:MONONA
Mailing Address - State:WI
Mailing Address - Zip Code:53716-3835
Mailing Address - Country:US
Mailing Address - Phone:608-234-7440
Mailing Address - Fax:
Practice Address - Street 1:6200 SYLVAN LN
Practice Address - Street 2:
Practice Address - City:MONONA
Practice Address - State:WI
Practice Address - Zip Code:53716-3835
Practice Address - Country:US
Practice Address - Phone:608-234-7440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1031164171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications