MEDICARE: IVELCA RODRIGUEZ AUD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	41YA00130100	NJ

General Provider Information

NPI Number	:	1336980390
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IVELCA RODRIGUEZ AUD

Provider Business Mailing Address
First Line	:	8901 KENNEDY BLVD STE 4S
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-5345
Country	:	US
Telephone Number	:	201-472-8500
Fax Number	:	201-472-8501

Provider Business Practice Location Address
First Line	:	8901 KENNEDY BLVD STE 4S
Second Line	:
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-5345
Country	:	US
Telephone Number	:	201-472-8500
Fax Number	:	201-472-8501

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2024
Last Update Date	:	06/04/2024

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