Provider Demographics
NPI:1710082573
Name:ROGERS, TRACY CLEMENT (MS RD LDN)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:CLEMENT
Last Name:ROGERS
Suffix:
Gender:F
Credentials:MS RD LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 N 35TH ST
Mailing Address - Street 2:SUITE B3
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-3183
Mailing Address - Country:US
Mailing Address - Phone:252-241-0369
Mailing Address - Fax:888-813-7814
Practice Address - Street 1:209 N 35TH ST
Practice Address - Street 2:SUITE B3
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3183
Practice Address - Country:US
Practice Address - Phone:252-241-0369
Practice Address - Fax:888-813-7814
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002454133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
2992505Medicare ID - Type Unspecified