MEDICARE: RJESUS LUIS RODRIGUEZ ADULT LIVING FACILIT

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	172V00000X	Community Health Worker	AL12078	FL

General Provider Information

NPI Number	:	1851648612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RJESUS LUIS RODRIGUEZ ADULT LIVING FACILIT

Provider Business Mailing Address
First Line	:	220 NW 179TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4910
Country	:	US
Telephone Number	:	305-454-9202
Fax Number	:	305-454-9202

Provider Business Practice Location Address
First Line	:	220 NW 179TH ST
Second Line	:
City	:	MIAMI GARDENS
State	:	FL
Zip	:	33169-4910
Country	:	US
Telephone Number	:	305-454-9202
Fax Number	:	305-454-9202

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

Provider Enumeration Date	:	08/12/2012
Last Update Date	:	08/12/2012

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