Healthcare Provider Details

I. General information

NPI: 1124370960
Provider Name (Legal Business Name): JASON RODRIGUEZ MBA, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1747 IMPERIAL BLVD
LAKE CHARLES LA
70605-5362
US

IV. Provider business mailing address

6832 CALDER ST
LAKE CHARLES LA
70605-0163
US

V. Phone/Fax

Practice location:
  • Phone: 337-721-7236
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.200098
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: