Provider Demographics
NPI:1952630469
Name:RODGERS, DALE ROTH (ATC/LAT)
Entity Type:Individual
Prefix:MS
First Name:DALE
Middle Name:ROTH
Last Name:RODGERS
Suffix:
Gender:F
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1267
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-6143
Mailing Address - Country:US
Mailing Address - Phone:940-627-7532
Mailing Address - Fax:940-627-7547
Practice Address - Street 1:2800 S FM 51 STE B
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-4002
Practice Address - Country:US
Practice Address - Phone:940-627-7532
Practice Address - Fax:940-627-7547
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-11
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT09662255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer