Provider Demographics
NPI:1477263002
Name:ROGERS, KENNETH E
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:E
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 1:251 E 244TH ST APT 101
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1470
Mailing Address - Country:US
Mailing Address - Phone:216-507-5933
Mailing Address - Fax:
Practice Address - Street 1:251 E 244TH ST APT 101
Practice Address - Street 2:
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-1470
Practice Address - Country:US
Practice Address - Phone:216-507-5933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-05
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRU856279171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator