Healthcare Provider Details

I. General information

NPI: 1982104188
Provider Name (Legal Business Name): MR. PETER RODRIQUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 02/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38710 ADCOCK DR
FREMONT CA
94536-4387
US

IV. Provider business mailing address

38710 ADCOCK DR
FREMONT CA
94536-4387
US

V. Phone/Fax

Practice location:
  • Phone: 510-938-8250
  • Fax:
Mailing address:
  • Phone: 510-938-8250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: