Healthcare Provider Details

I. General information

NPI: 1245620616
Provider Name (Legal Business Name): SOLY RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

749 SHOTGUN RD
SUNRISE FL
33326-1934
US

IV. Provider business mailing address

749 SHOTGUN RD
SUNRISE FL
33326-1934
US

V. Phone/Fax

Practice location:
  • Phone: 954-907-4869
  • Fax:
Mailing address:
  • Phone: 954-907-4869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberR3627181723650
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: