Healthcare Provider Details

I. General information

NPI: 1811417785
Provider Name (Legal Business Name): ALEJANDRO RODRIGUEZ MS, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 06/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1936 NORTH ST
NACOGDOCHES TX
75965-3940
US

IV. Provider business mailing address

1710 E STARR AVE APT 109
NACOGDOCHES TX
75961-4363
US

V. Phone/Fax

Practice location:
  • Phone: 936-468-3784
  • Fax: 936-468-4052
Mailing address:
  • Phone: 713-677-9580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT6694
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: