Healthcare Provider Details

I. General information

NPI: 1659044915
Provider Name (Legal Business Name): RODRIGO MANUEL CARUCO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2021
Last Update Date: 07/31/2021
Certification Date: 07/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 JANNEYS LN
ALEXANDRIA VA
22302-3918
US

IV. Provider business mailing address

525 N FAYETTE ST UNIT 321
ALEXANDRIA VA
22314-2270
US

V. Phone/Fax

Practice location:
  • Phone: 301-747-3181
  • Fax:
Mailing address:
  • Phone: 301-747-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: