Provider Demographics
NPI:1104659143
Name:LIM, RODEL AGAO
Entity type:Individual
Prefix:MR
First Name:RODEL
Middle Name:AGAO
Last Name:LIM
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 1:26243 NEWPORT AVE
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-4121
Mailing Address - Country:US
Mailing Address - Phone:619-850-9604
Mailing Address - Fax:
Practice Address - Street 1:126 AVOCADO AVE STE 106
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2605
Practice Address - Country:US
Practice Address - Phone:951-943-7212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-24
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty