Healthcare Provider Details

I. General information

NPI: 1740647486
Provider Name (Legal Business Name): MR. KLADE DANE RODRIGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MARION PUGH DR APT 104
COLLEGE STATION TX
77840-2702
US

IV. Provider business mailing address

P.O. BOX 22
SATIN TX
76685
US

V. Phone/Fax

Practice location:
  • Phone: 254-316-8275
  • Fax:
Mailing address:
  • Phone: 254-316-8275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number36849484
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: