Provider Demographics
NPI:1619431418
Name:RODRIGUEZ, JUAN MANUEL
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:MANUEL
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 1:3677 CENTRAL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-8226
Mailing Address - Country:US
Mailing Address - Phone:239-790-1263
Mailing Address - Fax:239-790-1074
Practice Address - Street 1:3677 CENTRAL AVE STE B
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8226
Practice Address - Country:US
Practice Address - Phone:239-790-1263
Practice Address - Fax:239-790-1074
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
FLMA91153225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty