1730806522 NPI number — ANA RODRIGUEZ LAC

Table of content: ANA RODRIGUEZ LAC (NPI 1730806522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730806522 NPI number — ANA RODRIGUEZ LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RODRIGUEZ
Provider First Name:
ANA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RODRIGUEZ ORTIZ
Provider Other First Name:
ANA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LAC
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1730806522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2809 FOREST HOME RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-5320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-972-1268
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1108 POPLAR PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72756-4249
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-372-6464
Provider Business Practice Location Address Fax Number:
479-372-6460
Provider Enumeration Date:
10/24/2022

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: 101YM0800X , with the licence number:  A2208012 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 291278795 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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