Provider Demographics
NPI:1235258260
Name:ROGERS, CHARLES LEWIS (OPA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:LEWIS
Last Name:ROGERS
Suffix:
Gender:M
Credentials:OPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 TRINITY LN
Mailing Address - Street 2:SUITE 111
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8111
Mailing Address - Country:US
Mailing Address - Phone:309-663-6461
Mailing Address - Fax:309-663-5711
Practice Address - Street 1:1111 TRINITY LN
Practice Address - Street 2:SUITE 111
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-8111
Practice Address - Country:US
Practice Address - Phone:309-663-6461
Practice Address - Fax:309-663-5711
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.000269246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant