Healthcare Provider Details

I. General information

NPI: 1346446549
Provider Name (Legal Business Name): CARLOS RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15519 CRENSHAW BLVD
GARDENA CA
90249-4525
US

IV. Provider business mailing address

2570 W 235TH ST APT 12
TORRANCE CA
90505-4267
US

V. Phone/Fax

Practice location:
  • Phone: 310-973-2272
  • Fax:
Mailing address:
  • Phone: 323-895-8414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC056640518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: