Provider Demographics
NPI:1609498153
Name:ROGERS, KEITH BERNARD
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:BERNARD
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 1:4711 CURRY FORD RD STE C
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32812-2704
Mailing Address - Country:US
Mailing Address - Phone:407-692-3824
Mailing Address - Fax:
Practice Address - Street 1:4711 CURRY FORD RD STE C
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32812-2704
Practice Address - Country:US
Practice Address - Phone:407-692-3824
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-07
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA69901225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist