Provider Demographics
NPI:1851708333
Name:ROGERS, JIMMIE
Entity Type:Individual
Prefix:
First Name:JIMMIE
Middle Name:
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 1:8500 PATRIOT BLVD
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29420-7415
Mailing Address - Country:US
Mailing Address - Phone:843-296-6810
Mailing Address - Fax:
Practice Address - Street 1:8500 PATRIOT BLVD
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29420-7415
Practice Address - Country:US
Practice Address - Phone:843-296-6810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer