Healthcare Provider Details

I. General information

NPI: 1578481883
Provider Name (Legal Business Name): MARCELL RENGIFO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1216 2ND ST SW
ROCHESTER MN
55902-1906
US

IV. Provider business mailing address

220 BROADWAY AVE S APT 1407
ROCHESTER MN
55904-6529
US

V. Phone/Fax

Practice location:
  • Phone: 507-255-5123
  • Fax:
Mailing address:
  • Phone: 631-327-1514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2508540
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: