Healthcare Provider Details

I. General information

NPI: 1962174862
Provider Name (Legal Business Name): RODNEY BERNICE HARRISON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 LEMON AVE APT 612
RANCHO CUCAMONGA CA
91737-3830
US

IV. Provider business mailing address

10801 LEMON AVE APT 612
RANCHO CUCAMONGA CA
91737-3830
US

V. Phone/Fax

Practice location:
  • Phone: 909-990-6019
  • Fax:
Mailing address:
  • Phone: 909-990-6019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225000000X
TaxonomyOrthotic Fitter
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: