Healthcare Provider Details

I. General information

NPI: 1588895387
Provider Name (Legal Business Name): JOHN ROBERT RHODEBACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2009
Last Update Date: 07/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11474 PINHOOK RD
ROCKVILLE VA
23146-1507
US

IV. Provider business mailing address

11474 PINHOOK RD
ROCKVILLE VA
23146-1507
US

V. Phone/Fax

Practice location:
  • Phone: 804-749-8628
  • Fax: 804-749-8425
Mailing address:
  • Phone: 804-749-8628
  • Fax: 804-749-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2705026348
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: