Healthcare Provider Details

I. General information

NPI: 1063612471
Provider Name (Legal Business Name): MR. FREDDIE RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 CALLE DON DIEGO VILLA FLORES
PONCE PR
00716-2921
US

IV. Provider business mailing address

29 CALLE B BELLA VSITA
PONCE PR
00730-2023
US

V. Phone/Fax

Practice location:
  • Phone: 787-671-8572
  • Fax: 787-651-6339
Mailing address:
  • Phone: 787-671-8572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1467
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: