1356579577 NPI number — MISS AGNES DAWN RODRIGUEZ PROVISIONAL LISW

Table of content: MISS AGNES DAWN RODRIGUEZ PROVISIONAL LISW (NPI 1356579577)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356579577 NPI number — MISS AGNES DAWN RODRIGUEZ PROVISIONAL LISW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ
Provider First Name:
AGNES
Provider Middle Name:
DAWN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PROVISIONAL LISW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356579577
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 553
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HI RLS MTN PK
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88325-0553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-443-6166
Provider Business Mailing Address Fax Number:
575-437-0755

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2150 HIGHWAY 54 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALAMOGORDO
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88310-7330
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-443-8133
Provider Business Practice Location Address Fax Number:
575-443-8055
Provider Enumeration Date:
06/25/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  I-07111 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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