Provider Demographics
NPI:1427930841
Name:LICH, RODNEY WAYNE (LAT/ATC)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:WAYNE
Last Name:LICH
Suffix:
Gender:M
Credentials:LAT/ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 BILOXI TRL
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-8207
Mailing Address - Country:US
Mailing Address - Phone:904-291-4453
Mailing Address - Fax:
Practice Address - Street 1:2999 BILOXI TRL
Practice Address - Street 2:
Practice Address - City:MIDDLEBURG
Practice Address - State:FL
Practice Address - Zip Code:32068-8207
Practice Address - Country:US
Practice Address - Phone:904-291-4453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL1762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer