Healthcare Provider Details

I. General information

NPI: 1265389076
Provider Name (Legal Business Name): AMANDA MYREA RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2026
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44750 60TH ST W
LANCASTER CA
93536-7619
US

IV. Provider business mailing address

2595 ATLANTA AVE SPC 76
RIVERSIDE CA
92507-2491
US

V. Phone/Fax

Practice location:
  • Phone: 661-729-2000
  • Fax:
Mailing address:
  • Phone: 951-263-0681
  • 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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: