Healthcare Provider Details

I. General information

NPI: 1922130558
Provider Name (Legal Business Name): BEN RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 SCENIC DR BLDG 4
MODESTO CA
95350-6131
US

IV. Provider business mailing address

800 SCENIC DR
MODESTO CA
95350-6131
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-6146
  • Fax: 209-525-5361
Mailing address:
  • Phone: 209-525-6146
  • Fax: 209-525-5361

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberRASI-051081
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: