Healthcare Provider Details

I. General information

NPI: 1215733688
Provider Name (Legal Business Name): RODRIGO HURTADO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2025
Last Update Date: 02/24/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10208 EL CAPITAN WAY
BALLICO CA
95303-9739
US

IV. Provider business mailing address

6400 TUPELO DR
CITRUS HEIGHTS CA
95621-1741
US

V. Phone/Fax

Practice location:
  • Phone: 209-259-5706
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: