Healthcare Provider Details

I. General information

NPI: 1194508630
Provider Name (Legal Business Name): SOFIA RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 3RD ST
LA VERNE CA
91750-4401
US

IV. Provider business mailing address

8815 KLINEDALE AVE
PICO RIVERA CA
90660-5533
US

V. Phone/Fax

Practice location:
  • Phone: 562-644-4616
  • Fax:
Mailing address:
  • Phone: 562-644-4616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: