Healthcare Provider Details

I. General information

NPI: 1447790589
Provider Name (Legal Business Name): JOSE RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13440 VENTURA BLVD SUITE 200
SHERMAN OAKS CA
91423-3850
US

IV. Provider business mailing address

6665 RHODES AVE APT #3
NORTH HOLLYWOOD CA
91606-1303
US

V. Phone/Fax

Practice location:
  • Phone: 818-442-0921
  • Fax:
Mailing address:
  • Phone: 818-915-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: