Provider Demographics
NPI:1164628806
Name:COGGIN, ROY LEE (CPED,COF)
Entity Type:Individual
Prefix:MR
First Name:ROY
Middle Name:LEE
Last Name:COGGIN
Suffix:
Gender:M
Credentials:CPED,COF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 690
Mailing Address - Street 2:
Mailing Address - City:FARMVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27828-0690
Mailing Address - Country:US
Mailing Address - Phone:252-753-2092
Mailing Address - Fax:252-753-2499
Practice Address - Street 1:3708 N MAIN ST.
Practice Address - Street 2:
Practice Address - City:FARMVILLE
Practice Address - State:NC
Practice Address - Zip Code:27828-1434
Practice Address - Country:US
Practice Address - Phone:252-753-2092
Practice Address - Fax:252-753-2499
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-21
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC224L00000X
225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795254Medicaid
NC7795300Medicaid