1669677498 NPI number — MRS. ROBIN RENEE CHILDRESS-RODRIGUEZ NP

Table of content: MRS. ROBIN RENEE CHILDRESS-RODRIGUEZ NP (NPI 1669677498)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669677498 NPI number — MRS. ROBIN RENEE CHILDRESS-RODRIGUEZ NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHILDRESS-RODRIGUEZ
Provider First Name:
ROBIN
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CHILDRESS
Provider Other First Name:
ROBIN
Provider Other Middle Name:
RENEE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669677498
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
230 7TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PACIFIC GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93950-3503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-373-6160
Provider Business Mailing Address Fax Number:
831-372-9320

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
690 DALLAS HWY
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
VILLA RICA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30180-1264
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-459-0620
Provider Business Practice Location Address Fax Number:
770-456-7604
Provider Enumeration Date:
06/20/2007

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: 363LF0000X , with the licence number:  RN141373 , 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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