Healthcare Provider Details

I. General information

NPI: 1639943699
Provider Name (Legal Business Name): SUZANNE ROSE RODRIGUEZ CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUZANNE ROSE RODRIGUEZ CPT

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 RIO BRAVO BLVD SW
ALBUQUERQUE NM
87105-5532
US

IV. Provider business mailing address

3040 RIO BRAVO BLVD SW
ALBUQUERQUE NM
87105-5532
US

V. Phone/Fax

Practice location:
  • Phone: 505-917-3963
  • Fax: 505-314-5443
Mailing address:
  • Phone: 505-917-3963
  • Fax: 505-314-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number1210728861
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: