Healthcare Provider Details

I. General information

NPI: 1710547195
Provider Name (Legal Business Name): JOSE RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 05/13/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9890 COUNTY FARM RD STE 3
RIVERSIDE CA
92503-3678
US

IV. Provider business mailing address

7630 GRAMERCY PL
RIVERSIDE CA
92503-2514
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-8320
  • Fax:
Mailing address:
  • Phone: 951-990-2401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number123374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: