Provider Demographics
NPI:1538943956
Name:THRASHER, ROGER L III
Entity type:Individual
Prefix:
First Name:ROGER
Middle Name:L
Last Name:THRASHER
Suffix:III
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 1:405 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 LEWIS ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:CA
Practice Address - Zip Code:90042-2111
Practice Address - Country:US
Practice Address - Phone:818-742-8087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA70967225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist