Healthcare Provider Details

I. General information

NPI: 1912603473
Provider Name (Legal Business Name): SAMUEL KALEB RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 02/06/2023
Certification Date: 02/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 BRADEN AVE
SARASOTA FL
34243-2001
US

IV. Provider business mailing address

2744 HERWALD ST
SARASOTA FL
34231-5116
US

V. Phone/Fax

Practice location:
  • Phone: 941-355-7637
  • Fax:
Mailing address:
  • Phone: 941-250-9458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: