Healthcare Provider Details

I. General information

NPI: 1770026437
Provider Name (Legal Business Name): RUBEN RODRIGUEZ JR. MA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 12/31/2024
Certification Date: 12/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5762 BOLSA AVE SUITE 101
HUNTINGTON BEACH CA
92649-1172
US

IV. Provider business mailing address

5762 BOLSA AVE SUITE 101
HUNTINGTON BEACH CA
92649-1172
US

V. Phone/Fax

Practice location:
  • Phone: 714-292-2322
  • Fax: 714-866-4153
Mailing address:
  • Phone: 714-292-2322
  • Fax: 714-866-4153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-23821
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: