Healthcare Provider Details

I. General information

NPI: 1730594698
Provider Name (Legal Business Name): ELIZABETH RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2014
Last Update Date: 06/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 DOLORES DR NW
ALBUQUERQUE NM
87105-1357
US

IV. Provider business mailing address

PO BOX 27283
ALBUQUERQUE NM
87125-7283
US

V. Phone/Fax

Practice location:
  • Phone: 505-400-9259
  • Fax:
Mailing address:
  • Phone: 505-400-9259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberFA0112269
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: