Provider Demographics
NPI:1205833852
Name:ROGER EICHMAN
Entity Type:Organization
Organization Name:ROGER EICHMAN
Other - Org Name:CENTER FOR EFFECTIVE LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:D
Authorized Official - Last Name:EICHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MS LP
Authorized Official - Phone:507-288-5675
Mailing Address - Street 1:1027 7TH ST NW
Mailing Address - Street 2:LEXINGTON BUILDING SUITE 1
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-2666
Mailing Address - Country:US
Mailing Address - Phone:507-288-5675
Mailing Address - Fax:507-288-4240
Practice Address - Street 1:1027 7TH ST NW
Practice Address - Street 2:LEXINGTON BUILDING SUITE 1
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-2666
Practice Address - Country:US
Practice Address - Phone:507-288-5675
Practice Address - Fax:507-288-4240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-28
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
MNLP0488103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN39231EIOtherBC/BS
MN120286300Medicaid