Provider Demographics
NPI:1932626272
Name:GREEN, ROGERICK SR
Entity Type:Individual
Prefix:MR
First Name:ROGERICK
Middle Name:
Last Name:GREEN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7853 GUNN HWY # 133
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1611
Mailing Address - Country:US
Mailing Address - Phone:813-297-8112
Mailing Address - Fax:877-799-6786
Practice Address - Street 1:7853 GUNN HWY # 133
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1611
Practice Address - Country:US
Practice Address - Phone:813-297-8112
Practice Address - Fax:877-799-6786
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator