Healthcare Provider Details

I. General information

NPI: 1851861652
Provider Name (Legal Business Name): JUDITH RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2018
Last Update Date: 12/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 RANCHEROS DR STE 166
SAN MARCOS CA
92069-2980
US

IV. Provider business mailing address

1318 LEMON ST
OCEANSIDE CA
92058-2615
US

V. Phone/Fax

Practice location:
  • Phone: 760-744-3672
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number104978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: