Provider Demographics
NPI:1154971729
Name:RODRIGUEZ, RUBEN KIM
Entity type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:KIM
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 1:9363 SYLMAR AVE APT 7
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-1372
Mailing Address - Country:US
Mailing Address - Phone:818-294-3726
Mailing Address - Fax:
Practice Address - Street 1:762 GRISWOLD AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-2105
Practice Address - Country:US
Practice Address - Phone:747-500-9415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6624-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)