Healthcare Provider Details

I. General information

NPI: 1558195586
Provider Name (Legal Business Name): RODRIGUE TIASSOU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2024
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 E 120TH ST
LOS ANGELES CA
90059-3052
US

IV. Provider business mailing address

309 MONSON LN APT E
SAN GABRIEL CA
91776-2480
US

V. Phone/Fax

Practice location:
  • Phone: 323-668-4776
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: