Provider Demographics
NPI:1992830038
Name:MASSA, RODGER WESLEY (DC)
Entity Type:Individual
Prefix:
First Name:RODGER
Middle Name:WESLEY
Last Name:MASSA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 N US 27
Mailing Address - Street 2:
Mailing Address - City:ST JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879
Mailing Address - Country:US
Mailing Address - Phone:989-224-8228
Mailing Address - Fax:989-224-2157
Practice Address - Street 1:1004 N US 27
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879
Practice Address - Country:US
Practice Address - Phone:989-224-8228
Practice Address - Fax:989-224-2157
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRM005731111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000000002355OtherPHP
950A95135OtherBC
MI2712107Medicaid
950A95135OtherBC
MI2712107Medicaid