Provider Demographics
NPI:1649706425
Name:RODRIGUEZ, EDGAR (DC)
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:EDGAR
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:4507 BRIDGEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-1940
Mailing Address - Country:US
Mailing Address - Phone:562-415-3805
Mailing Address - Fax:
Practice Address - Street 1:4507 BRIDGEVIEW AVE
Practice Address - Street 2:
Practice Address - City:PICO RIVERA
Practice Address - State:CA
Practice Address - Zip Code:90660-1940
Practice Address - Country:US
Practice Address - Phone:562-415-3805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33517111N00000X, 111NP0017X, 111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
No111N00000XChiropractic ProvidersChiropractor
No111NP0017XChiropractic ProvidersChiropractorPediatric Chiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation