Basic Information
| Provider Information | |||||||||
| NPI: | 1235258260 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | LEWIS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | OPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 TRINITY LN | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
| FaxNumber: | 3096635711 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 TRINITY LN | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 617048111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3096636461 | ||||||||
| FaxNumber: | 3096635711 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 238.000269 | IL | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.