Provider Demographics
NPI:1063612471
Name:RODRIGUEZ, FREDDIE
Entity type:Individual
Prefix:MR
First Name:FREDDIE
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 CALLE B
Mailing Address - Street 2:BELLA VSITA
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00730-2023
Mailing Address - Country:US
Mailing Address - Phone:787-671-8572
Mailing Address - Fax:
Practice Address - Street 1:2707 CALLE DON DIEGO
Practice Address - Street 2:VILLA FLORES
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00716-2921
Practice Address - Country:US
Practice Address - Phone:787-671-8572
Practice Address - Fax:787-651-6339
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1467133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist