Provider Demographics
NPI:1275503187
Name:RODGERS, STACEY L (DC)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:RODGERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 W DAVIS ST
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-1862
Mailing Address - Country:US
Mailing Address - Phone:936-441-9990
Mailing Address - Fax:936-441-9991
Practice Address - Street 1:2253 C NORTH LOOP 336 W
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3630
Practice Address - Country:US
Practice Address - Phone:936-441-9990
Practice Address - Fax:936-441-9991
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-24
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8856111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX172876801Medicaid
V02213Medicare UPIN
TX172876801Medicaid