Basic Information
| Provider Information | |||||||||
| NPI: | 1831448182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECERRA | ||||||||
| FirstName: | ROGELIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 673 MDG | ||||||||
| Address2: | 5955 ZEAMER AVE | ||||||||
| City: | JBER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075802181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 673 MDG | ||||||||
| Address2: | 5955 ZEAMER AVE | ||||||||
| City: | JBER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 90805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9075802181 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2012 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 104100000X | 253005 | KY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.