Provider Demographics
NPI:1942890728
Name:RODRIGUEZ, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:RODRIGUEZ
Suffix:
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 1:1811 RALLY LN
Mailing Address - Street 2:
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-6032
Mailing Address - Country:US
Mailing Address - Phone:830-992-9770
Mailing Address - Fax:
Practice Address - Street 1:1880 WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:SALADO
Practice Address - State:TX
Practice Address - Zip Code:76571-6263
Practice Address - Country:US
Practice Address - Phone:254-947-6990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT66432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer