Provider Demographics
NPI:1245475748
Name:MOLINA, ROGER (CPO)
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:MOLINA
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 N. CHRISMAN ROAD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95304-9314
Mailing Address - Country:US
Mailing Address - Phone:209-526-1721
Mailing Address - Fax:209-526-1740
Practice Address - Street 1:609 E. ORANGEBURG AVENUE
Practice Address - Street 2:SUITE 102
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5512
Practice Address - Country:US
Practice Address - Phone:209-526-1721
Practice Address - Fax:209-526-1740
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO00577224P00000X
CACPO0057222Z00000X, 225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter