Healthcare Provider Details

I. General information

NPI: 1730094483
Provider Name (Legal Business Name): ROD G MOSQUERA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4975 45TH AVE SE
LACEY WA
98503-4305
US

IV. Provider business mailing address

4975 45TH AVE SE
LACEY WA
98503-4305
US

V. Phone/Fax

Practice location:
  • Phone: 360-561-1007
  • Fax: 360-995-5027
Mailing address:
  • Phone: 360-561-1007
  • Fax: 360-995-5027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number759124
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: