Provider Demographics
NPI:1255862413
Name:VASQUEZ SANDOVAL, RODRIGO (PT)
Entity type:Individual
Prefix:
First Name:RODRIGO
Middle Name:
Last Name:VASQUEZ SANDOVAL
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:713 W WADE HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:GREER
Practice Address - State:SC
Practice Address - Zip Code:29650-1307
Practice Address - Country:US
Practice Address - Phone:864-479-6084
Practice Address - Fax:864-479-6091
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY038688225100000X
SC12382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist