Provider Demographics
NPI:1205231024
Name:RODRIGUEZ, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
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 1:855 N PARK RD
Mailing Address - Street 2:APT C-303
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1308
Mailing Address - Country:US
Mailing Address - Phone:610-685-1444
Mailing Address - Fax:610-685-1441
Practice Address - Street 1:855 N PARK RD
Practice Address - Street 2:APT C-303
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1308
Practice Address - Country:US
Practice Address - Phone:610-685-1444
Practice Address - Fax:610-685-1441
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG009432225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist