Provider Demographics
NPI:1700813680
Name:ROGERS, IDA M (DC)
Entity type:Individual
Prefix:DR
First Name:IDA
Middle Name:M
Last Name:ROGERS
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2748 MILTON WAY
Mailing Address - Street 2:STE 211
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-9382
Mailing Address - Country:US
Mailing Address - Phone:253-952-0302
Mailing Address - Fax:253-952-0307
Practice Address - Street 1:2748 MILTON WAY
Practice Address - Street 2:STE 211
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-9382
Practice Address - Country:US
Practice Address - Phone:253-952-0302
Practice Address - Fax:253-952-0307
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002813111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU41402Medicare UPIN