Healthcare Provider Details

I. General information

NPI: 1093353633
Provider Name (Legal Business Name): CARLOS RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 04/16/2020
Certification Date: 04/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PROGRAMA SIDA DE SAN JUAN AVE FERNANDEZ JUNCOS 1306
SAN JUAN PR
00908
US

IV. Provider business mailing address

PO BOX 37126
SAN JUAN PR
00937-0126
US

V. Phone/Fax

Practice location:
  • Phone: 787-480-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number76664
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number17677
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number17677
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: