Healthcare Provider Details

I. General information

NPI: 1467009746
Provider Name (Legal Business Name): LUZBERTO RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W 87TH AVE
MERRILLVILLE IN
46410-6177
US

IV. Provider business mailing address

7780 CAROLINA PL
MERRILLVILLE IN
46410-5629
US

V. Phone/Fax

Practice location:
  • Phone: 219-756-0744
  • Fax:
Mailing address:
  • Phone: 219-689-2681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160003862
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06002840A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: