Basic Information
| Provider Information | |||||||||
| NPI: | 1275817025 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RODRIGUEZ | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | B.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11813 WOLCOTT ST | ||||||||
| Address2: | |||||||||
| City: | ADELANTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923013737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097258508 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1460 E HOLT AVE | ||||||||
| Address2: | #8 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098650209 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2011 | ||||||||
| LastUpdateDate: | 09/28/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.