Healthcare Provider Details

I. General information

NPI: 1053859496
Provider Name (Legal Business Name): JOSE RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4721 SUNSET BLVD SUITE D
LEXINGTON SC
29072-9151
US

IV. Provider business mailing address

6 MILLET RIDGE CT
COLUMBIA SC
29223-1402
US

V. Phone/Fax

Practice location:
  • Phone: 803-996-0312
  • Fax: 803-957-2496
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1163
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: