Healthcare Provider Details

I. General information

NPI: 1477286334
Provider Name (Legal Business Name): ANGEL RODRIGUEZ JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2022
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 W HENDERSON AVE STE 2
PORTERVILLE CA
93257-1490
US

IV. Provider business mailing address

1055 W HENDERSON AVE STE 21055W
PORTERVILLE CA
93257-1490
US

V. Phone/Fax

Practice location:
  • Phone: 559-788-1200
  • Fax:
Mailing address:
  • Phone: 559-788-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number34746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: