Healthcare Provider Details

I. General information

NPI: 1588578959
Provider Name (Legal Business Name): BOBBY LOUIS RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

84 E MOUND ST
JACKSON OH
45640-1226
US

IV. Provider business mailing address

84 E MOUND ST
JACKSON OH
45640-1226
US

V. Phone/Fax

Practice location:
  • Phone: 740-577-3834
  • Fax:
Mailing address:
  • Phone: 740-577-3834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: