Provider Demographics
NPI:1750090650
Name:RODRIGUEZ, RAFAEL (LAC)
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N MIDDLETOWN RD STE 2
Mailing Address - Street 2:
Mailing Address - City:PEARL RIVER
Mailing Address - State:NY
Mailing Address - Zip Code:10965-1295
Mailing Address - Country:US
Mailing Address - Phone:845-362-8400
Mailing Address - Fax:845-362-8474
Practice Address - Street 1:300 N MIDDLETOWN RD STE 2
Practice Address - Street 2:
Practice Address - City:PEARL RIVER
Practice Address - State:NY
Practice Address - Zip Code:10965-1295
Practice Address - Country:US
Practice Address - Phone:845-362-8400
Practice Address - Fax:845-362-8474
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-18
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026164-01225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist