Provider Demographics
NPI:1922493170
Name:RANDOLPH RODRIGUEZ
Entity Type:Organization
Organization Name:RANDOLPH RODRIGUEZ
Other - Org Name:RANDOLPH RODRIGUEZ
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:407-558-5656
Mailing Address - Street 1:2434 BENJAMIN DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-2722
Mailing Address - Country:US
Mailing Address - Phone:407-558-5656
Mailing Address - Fax:321-251-6542
Practice Address - Street 1:2434 BENJAMIN DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-2722
Practice Address - Country:US
Practice Address - Phone:407-558-5656
Practice Address - Fax:321-251-6542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-04
Last Update Date:2015-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA 138343140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric