Healthcare Provider Details

I. General information

NPI: 1922922822
Provider Name (Legal Business Name): ELISA M RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 MAIN ST
FORTUNA CA
95540-2006
US

IV. Provider business mailing address

2508 SHAY CT
FORTUNA CA
95540-2852
US

V. Phone/Fax

Practice location:
  • Phone: 707-362-3857
  • Fax:
Mailing address:
  • Phone: 707-740-9176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number30000813L
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: