Provider Demographics
NPI:1699015115
Name:RODGERS, DAVID (LN, MS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:RODGERS
Suffix:
Gender:M
Credentials:LN, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14097 VICTORIA ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1411
Mailing Address - Country:US
Mailing Address - Phone:248-291-7722
Mailing Address - Fax:248-636-4606
Practice Address - Street 1:2585 SUNNYKNOLL AVE STE 201
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1530
Practice Address - Country:US
Practice Address - Phone:248-291-7722
Practice Address - Fax:248-636-4606
Is Sole Proprietor?:No
Enumeration Date:2013-02-20
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN201133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist