MEDICARE: MS. ROSANNA RENEE RODRIGUEZ IDC

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1699927632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ROSANNA RENEE RODRIGUEZ IDC

Provider Business Mailing Address
First Line	:	2250 STANLEY RD
Second Line	:	SUITE 36
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-2640
Country	:	US
Telephone Number	:	210-295-8606
Fax Number	:	210-221-1200

Provider Business Practice Location Address
First Line	:	2250 STANLEY RD
Second Line	:	SUITE 36
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-2640
Country	:	US
Telephone Number	:	210-295-8606
Fax Number	:	210-221-1200

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

Provider Enumeration Date	:	10/22/2008
Last Update Date	:	10/22/2008

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