Provider Demographics
NPI:1437772258
Name:CARABALLO RODRIGUEZ, CRISTIAN JOSE LEOPOLDO
Entity Type:Individual
Prefix:
First Name:CRISTIAN
Middle Name:JOSE LEOPOLDO
Last Name:CARABALLO RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CRISTIAN
Other - Middle Name:JOSE
Other - Last Name:CARABALLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2509 JOHNSTON ST APT 7-06
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-3261
Mailing Address - Country:US
Mailing Address - Phone:337-889-8043
Mailing Address - Fax:
Practice Address - Street 1:2509 JOHNSTON ST APT 7-06
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-3261
Practice Address - Country:US
Practice Address - Phone:337-889-8043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator