Provider Demographics
NPI:1558714923
Name:ROGERS, EDWARD B JR (MT)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:B
Last Name:ROGERS
Suffix:JR
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3821 ATLANTIC AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-3534
Mailing Address - Country:US
Mailing Address - Phone:562-940-5450
Mailing Address - Fax:562-424-3235
Practice Address - Street 1:3821 ATLANTIC AVE
Practice Address - Street 2:SUITE F
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-3534
Practice Address - Country:US
Practice Address - Phone:562-940-5450
Practice Address - Fax:562-424-3235
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60893171W00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171W00000XOther Service ProvidersContractor