Provider Demographics
NPI:1891495040
Name:RODRIGUEZ, MANUEL JUNIOR SR
Entity Type:Individual
Prefix:
First Name:MANUEL
Middle Name:JUNIOR
Last Name:RODRIGUEZ
Suffix:SR
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:PO BOX 153
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:PR
Mailing Address - Zip Code:00786-0153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PASEOS DORADOS #66 CAYEY P.R 0
Practice Address - Street 2:
Practice Address - City:CAYEY
Practice Address - State:PR
Practice Address - Zip Code:00736
Practice Address - Country:US
Practice Address - Phone:787-664-1501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR129571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR1008070621OtherPRACTICE PRIVATE