1134765621 NPI number — MRS. ROSMERY DEL CARMEN JIMENEZ DE RODRIGUEZ

Table of content: MRS. ROSMERY DEL CARMEN JIMENEZ DE RODRIGUEZ (NPI 1134765621)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134765621 NPI number — MRS. ROSMERY DEL CARMEN JIMENEZ DE RODRIGUEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JIMENEZ DE RODRIGUEZ
Provider First Name:
ROSMERY
Provider Middle Name:
DEL CARMEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JIMENEZ DE RODRIGUEZ
Provider Other First Name:
ROSMERY
Provider Other Middle Name:
DEL CARMEN
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1134765621
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 RUBIL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DEMOREST
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30535-4871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
787-797-1956
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
140 MIDWAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORNELIA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30531-7148
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-894-9374
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2019

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: 225700000X , with the licence number:  MT010531 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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