Provider Demographics
NPI:1144584780
Name:RODRIGUEZ, REGLA D
Entity Type:Individual
Prefix:
First Name:REGLA
Middle Name:D
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2666 SW ACE RD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2815
Mailing Address - Country:US
Mailing Address - Phone:772-985-8841
Mailing Address - Fax:772-237-5186
Practice Address - Street 1:2666 SW ACE RD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34953-2815
Practice Address - Country:US
Practice Address - Phone:772-985-8841
Practice Address - Fax:772-237-5186
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-28
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12184310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility