Provider Demographics
NPI:1114762978
Name:RODRIGUEZ, MADISON GRACE
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:GRACE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7978 COUNTY FARM RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-9774
Mailing Address - Country:US
Mailing Address - Phone:616-862-2491
Mailing Address - Fax:
Practice Address - Street 1:7978 COUNTY FARM RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-9774
Practice Address - Country:US
Practice Address - Phone:616-862-2491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-25
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator