Healthcare Provider Details

I. General information

NPI: 1275860603
Provider Name (Legal Business Name): MICHAEL J. RODRIGUEZ SUBMARINE IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2009
Last Update Date: 11/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 CLARK ST. NSSC MEDICAL SUITE 400
PEARL HARBOR HI
96860
US

IV. Provider business mailing address

USS KEY WEST #SSN722
FPO AP
96683-2402
US

V. Phone/Fax

Practice location:
  • Phone: 808-473-3771
  • Fax: 808-473-3109
Mailing address:
  • Phone: 808-471-5625
  • Fax: 808-473-3109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: