MEDICARE: DR. SAMUEL WILLIAM RODRIGUEZ

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	111N00000X	Chiropractor	8694	AZ
2	111NS0005X	Sports Physician Chiropractor	8694	AZ
3	111NR0400X	Rehabilitation Chiropractor	8694	AZ

General Provider Information

NPI Number	:	1639667009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SAMUEL WILLIAM RODRIGUEZ

Provider Business Mailing Address
First Line	:	4140 E BASELINE RD STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-4413
Country	:	US
Telephone Number	:	480-233-9505
Fax Number	:

Provider Business Practice Location Address
First Line	:	4140 E BASELINE RD STE 101
Second Line	:
City	:	MESA
State	:	AZ
Zip	:	85206-4413
Country	:	US
Telephone Number	:	480-233-9505
Fax Number	:

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

Provider Enumeration Date	:	05/01/2018
Last Update Date	:	05/26/2023

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