=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760514905
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLE HAGEL RODRIGUEZ P.T.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 712 W MAIN ST STE A
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78624-3134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-997-3781
-----------------------------------------------------
Fax | 830-997-3786
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3637 RIVER RD
-----------------------------------------------------
City | FREDERICKSBURG
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78624-8182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 830-990-0291
-----------------------------------------------------
Fax | 830-997-3786
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1072932
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------