Provider Demographics
NPI:1972084820
Name:RODDA, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:RODDA
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 1:10184 NW 126TH TER
Mailing Address - Street 2:
Mailing Address - City:HIALEAH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33018-7429
Mailing Address - Country:US
Mailing Address - Phone:786-398-0674
Mailing Address - Fax:
Practice Address - Street 1:10184 NW 126TH TER
Practice Address - Street 2:
Practice Address - City:HIALEAH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33018-7429
Practice Address - Country:US
Practice Address - Phone:786-398-0674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty