Healthcare Provider Details

I. General information

NPI: 1336609304
Provider Name (Legal Business Name): KENEISHA KRISTAL RIOS-RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 MAGIC HOLLOW BLVD
VIRGINIA BEACH VA
23453-3010
US

IV. Provider business mailing address

384 DODGE DR
VIRGINIA BEACH VA
23452-6743
US

V. Phone/Fax

Practice location:
  • Phone: 757-639-2218
  • Fax: 866-594-3899
Mailing address:
  • Phone: 215-279-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: