Healthcare Provider Details

I. General information

NPI: 1386112522
Provider Name (Legal Business Name): BRENDA RODRIGUEZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

IV. Provider business mailing address

925 E I ST
ONTARIO CA
91764-3501
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1411
  • Fax: 877-720-7181
Mailing address:
  • Phone: 909-957-4322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86090208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: