Healthcare Provider Details

I. General information

NPI: 1134765621
Provider Name (Legal Business Name): MRS. ROSMERY DEL CARMEN JIMENEZ DE RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROSMERY DEL CARMEN JIMENEZ DE RODRIGUEZ LMT

II. Dates (important events)

Enumeration Date: 11/20/2019
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 MIDWAY DR
CORNELIA GA
30531-7148
US

IV. Provider business mailing address

165 RUBIL WAY
DEMOREST GA
30535-4871
US

V. Phone/Fax

Practice location:
  • Phone: 706-894-9374
  • Fax:
Mailing address:
  • Phone: 787-797-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT010531
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: