Basic Information
Provider Information
NPI: 1629408141
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ROGERS
FirstName: SCOTT
MiddleName: ERWIN
NamePrefix:  
NameSuffix: JR.
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5957 S MOONEY BLVD
Address2:  
City: VISALIA
State: CA
PostalCode: 932779394
CountryCode: US
TelephoneNumber: 5596248000
FaxNumber: 5597374697
Practice Location
Address1: 520 E TULARE AVE
Address2:  
City: VISALIA
State: CA
PostalCode: 932923629
CountryCode: US
TelephoneNumber: 5596230900
FaxNumber: 5597374697
Other Information
ProviderEnumerationDate: 11/19/2013
LastUpdateDate: 11/19/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
171M00000X  Y Other Service ProvidersCase Manager/Care Coordinator 

No ID Information.


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