Provider Demographics
NPI:1659772952
Name:RODRIGUEZ, FERNANDO (PTA)
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8105 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:IL
Mailing Address - Zip Code:60459-1733
Mailing Address - Country:US
Mailing Address - Phone:312-848-9362
Mailing Address - Fax:
Practice Address - Street 1:8105 NASHVILLE AVE
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1733
Practice Address - Country:US
Practice Address - Phone:312-848-9362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-06
Last Update Date:2014-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160005776225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant