Healthcare Provider Details

I. General information

NPI: 1134716160
Provider Name (Legal Business Name): ROGELIO JR IBARRA RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 12/23/2020
Certification Date: 12/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 HARRISON ST
RIVERSIDE CA
92503-3523
US

IV. Provider business mailing address

1080 MARINA VILLAGE PKWY
ALAMEDA CA
94501-6427
US

V. Phone/Fax

Practice location:
  • Phone: 833-391-0505
  • Fax: 951-358-7401
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: