Provider Demographics
NPI:1104513647
Name:RODRIGUEZ, JOHNATHAN BRANDON
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:BRANDON
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 1:345 PRINCE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-4515
Mailing Address - Country:US
Mailing Address - Phone:682-381-7376
Mailing Address - Fax:
Practice Address - Street 1:345 PRINCE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-4515
Practice Address - Country:US
Practice Address - Phone:682-381-7376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant