Healthcare Provider Details

I. General information

NPI: 1225618762
Provider Name (Legal Business Name): ERIC RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 PARK AVE
MODESTO CA
95354-0556
US

IV. Provider business mailing address

101 PARK AVE
MODESTO CA
95354-0556
US

V. Phone/Fax

Practice location:
  • Phone: 209-491-0872
  • Fax:
Mailing address:
  • Phone:
  • 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 State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: