Provider Demographics
NPI:1053180984
Name:ROGERS, LARRY D JR
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:D
Last Name:ROGERS
Suffix:JR
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 1:1204 N FORMOSA AVE APT D
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6185
Mailing Address - Country:US
Mailing Address - Phone:818-839-1709
Mailing Address - Fax:
Practice Address - Street 1:1204 N FORMOSA AVE APT D
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6185
Practice Address - Country:US
Practice Address - Phone:818-839-1709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-20
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA67091225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist