Provider Demographics
NPI:1073888178
Name:RODRIGUEZ, JOSE
Entity Type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10348 W RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:TOLLESON
Mailing Address - State:AZ
Mailing Address - Zip Code:85353-7639
Mailing Address - Country:US
Mailing Address - Phone:602-348-8857
Mailing Address - Fax:
Practice Address - Street 1:10348 W RAYMOND ST
Practice Address - Street 2:
Practice Address - City:TOLLESON
Practice Address - State:AZ
Practice Address - Zip Code:85353-7639
Practice Address - Country:US
Practice Address - Phone:602-348-8857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-21
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
AZ2000704385HR2055X, 253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child