Provider Demographics
NPI:1720468853
Name:ROGERS, TENNILLE
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:
Last Name:ROGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 W MAIN ST
Mailing Address - Street 2:1633
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512-3159
Mailing Address - Country:US
Mailing Address - Phone:570-846-7979
Mailing Address - Fax:
Practice Address - Street 1:208 W MAIN ST
Practice Address - Street 2:1633
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512-3159
Practice Address - Country:US
Practice Address - Phone:570-846-7979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC47-4177600OtherEIN