Provider Demographics
NPI:1538305347
Name:ROGERS, STACY MARIE
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:MARIE
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N MARTIN LUTHER KING HWY
Mailing Address - Street 2:#250
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-2000
Mailing Address - Country:US
Mailing Address - Phone:337-437-3791
Mailing Address - Fax:337-437-3793
Practice Address - Street 1:1200 N MARTIN LUTHER KING HWY
Practice Address - Street 2:#250
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-2000
Practice Address - Country:US
Practice Address - Phone:337-437-3791
Practice Address - Fax:337-437-3793
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-29
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200573291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19D1094002OtherCLIA
LA1793701Medicaid
LA19D1094002OtherCLIA