Healthcare Provider Details

I. General information

NPI: 1235394271
Provider Name (Legal Business Name): GLORY E RODRIGUEZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 02/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8330 LYNDON B JOHNSON FWY STE B650
DALLAS TX
75243-1166
US

IV. Provider business mailing address

10754 MIDWAY DR
FRISCO TX
75035
UM

V. Phone/Fax

Practice location:
  • Phone: 469-619-6921
  • Fax:
Mailing address:
  • Phone: 787-559-6617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number896265
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number1311
License Number StatePR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: