Healthcare Provider Details

I. General information

NPI: 1205679834
Provider Name (Legal Business Name): SAMANTHA RIVAS RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11655 QUEENS BLVD STE 216
FOREST HILLS NY
11375-6527
US

IV. Provider business mailing address

2104 BRONX PARK E APT 3A
BRONX NY
10462-2212
US

V. Phone/Fax

Practice location:
  • Phone: 212-470-1382
  • Fax:
Mailing address:
  • Phone: 347-324-4978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: