Provider Demographics
NPI:1710630843
Name:RODELO, RAUL JAY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:RAUL
Middle Name:JAY
Last Name:RODELO
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:RJ
Other - Middle Name:JAY
Other - Last Name:RODELO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:5820 DIAMOND OAKS DR S
Mailing Address - Street 2:
Mailing Address - City:HALTOM CITY
Mailing Address - State:TX
Mailing Address - Zip Code:76117-2862
Mailing Address - Country:US
Mailing Address - Phone:682-557-8120
Mailing Address - Fax:
Practice Address - Street 1:1333 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-4168
Practice Address - Country:US
Practice Address - Phone:254-963-9175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-29
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT88222255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer