Provider Demographics
NPI:1053724500
Name:RODGERS, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6439 GARNERS FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29209
Mailing Address - Country:US
Mailing Address - Phone:803-776-4000
Mailing Address - Fax:803-695-7932
Practice Address - Street 1:6439 GARNERS FERRY RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29209-1638
Practice Address - Country:US
Practice Address - Phone:803-776-4000
Practice Address - Fax:803-695-7932
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1736174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1736OtherKINESIOTHERAPY CERTIFICATION