Healthcare Provider Details

I. General information

NPI: 1932012127
Provider Name (Legal Business Name): MYKEL RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2026
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

651 TANK FARM RD
SAN LUIS OBISPO CA
93401-7062
US

IV. Provider business mailing address

651 TANK FARM RD
SAN LUIS OBISPO CA
93401-7062
US

V. Phone/Fax

Practice location:
  • Phone: 805-621-7651
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: