Healthcare Provider Details

I. General information

NPI: 1992989131
Provider Name (Legal Business Name): JORGE RODRIGUEZ O.T.C./C.S.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12264 EL CAMINO REAL SUITE 101
SAN DIEGO CA
92130-3060
US

IV. Provider business mailing address

12264 EL CAMINO REAL SUITE 101
SAN DIEGO CA
92130-3060
US

V. Phone/Fax

Practice location:
  • Phone: 858-847-0800
  • Fax: 858-724-0450
Mailing address:
  • Phone: 858-847-0800
  • Fax: 858-724-0450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number050842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: