Provider Demographics
NPI:1780061267
Name:ROGERS MASSAGE THERAPY CLINIC
Entity type:Organization
Organization Name:ROGERS MASSAGE THERAPY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:CORRALES
Authorized Official - Suffix:
Authorized Official - Credentials:LMT
Authorized Official - Phone:321-439-1361
Mailing Address - Street 1:1061 E. ALTAMONTE DRIVE
Mailing Address - Street 2:1019
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701
Mailing Address - Country:US
Mailing Address - Phone:321-439-1361
Mailing Address - Fax:
Practice Address - Street 1:1061 EAST ALTAMONTE DR
Practice Address - Street 2:SUITE 1019
Practice Address - City:ALTAMONTE SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32701
Practice Address - Country:US
Practice Address - Phone:321-439-1361
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMM11608305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service