Provider Demographics
NPI:1851102610
Name:RODRIGUEZ, VICTOR MANUEL
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:MANUEL
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 1:39 CIMARRON
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9617
Mailing Address - Country:US
Mailing Address - Phone:945-230-2062
Mailing Address - Fax:
Practice Address - Street 1:39 CIMARRON
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-9617
Practice Address - Country:US
Practice Address - Phone:945-230-2062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-20
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNC000-152-726-100347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle