Provider Demographics
NPI:1851648612
Name:RODRIGUEZ, RJESUS LUIS (ADULT LIVING FACILIT)
Entity Type:Individual
Prefix:
First Name:RJESUS
Middle Name:LUIS
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:ADULT LIVING FACILIT
Other - Prefix:
Other - First Name:IRISLEYDIS
Other - Middle Name:DAYAMIL
Other - Last Name:SANCHEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ADULT LIVING FACILIT
Mailing Address - Street 1:220 NW 179TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-4910
Mailing Address - Country:US
Mailing Address - Phone:305-454-9202
Mailing Address - Fax:305-454-9202
Practice Address - Street 1:220 NW 179TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33169-4910
Practice Address - Country:US
Practice Address - Phone:305-454-9202
Practice Address - Fax:305-454-9202
Is Sole Proprietor?:No
Enumeration Date:2012-08-12
Last Update Date:2012-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL12078172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker