Healthcare Provider Details

I. General information

NPI: 1912264037
Provider Name (Legal Business Name): MARIO GREGORIO RODRIGUEZ PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3056 SANDSTONE CIRCLE
ST CLOUD FL
34772
US

IV. Provider business mailing address

3056 SANDSTONE CIR
SAINT CLOUD FL
34772-6525
US

V. Phone/Fax

Practice location:
  • Phone: 407-957-7819
  • Fax:
Mailing address:
  • Phone: 407-957-7819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPT 11740
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: