Healthcare Provider Details

I. General information

NPI: 1770146730
Provider Name (Legal Business Name): MAYNOR R RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

328 E BROAD ST APT 1
HAZLETON PA
18201-6650
US

IV. Provider business mailing address

PO BOX 2438
HAZLETON PA
18201-8438
US

V. Phone/Fax

Practice location:
  • Phone: 570-497-4070
  • Fax: 570-300-1802
Mailing address:
  • Phone: 570-497-4070
  • Fax: 570-300-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code343800000X
TaxonomySecured Medical Transport (VAN)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347B00000X
TaxonomyBus
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: