Provider Demographics
NPI:1811021280
Name:RODRIGUEZ, IMELDA
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 TAMARIND AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-2235
Mailing Address - Country:US
Mailing Address - Phone:909-350-8813
Mailing Address - Fax:
Practice Address - Street 1:2555 E COLORADO BLVD
Practice Address - Street 2:SUITE 100-101
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-6622
Practice Address - Country:US
Practice Address - Phone:626-577-2261
Practice Address - Fax:626-577-2543
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAICAN671OtherLACDMH STAFF CODE