Healthcare Provider Details

I. General information

NPI: 1841014834
Provider Name (Legal Business Name): RUDY RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31700 FAYETTEVILLE DR
SHEDD OR
97377-9779
US

IV. Provider business mailing address

18600 SE MCLOUGHLIN BLVD
MILWAUKIE OR
97267-6723
US

V. Phone/Fax

Practice location:
  • Phone: 503-208-9004
  • Fax:
Mailing address:
  • Phone: 971-255-0658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: