Healthcare Provider Details

I. General information

NPI: 1891495040
Provider Name (Legal Business Name): MANUEL JUNIOR RODRIGUEZ SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2023
Last Update Date: 03/07/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PASEOS DORADOS #66 CAYEY P.R 0
CAYEY PR
00736
US

IV. Provider business mailing address

PO BOX 153
LA PLATA PR
00786-0153
US

V. Phone/Fax

Practice location:
  • Phone: 787-664-1501
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12957
License Number StatePR

VII. Legacy identifiers

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

# 1
Identifier1008070621
Identifier TypeOTHER
Identifier StatePR
Identifier IssuerPRACTICE PRIVATE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: