Provider Demographics
NPI:1962902791
Name:RODRIGUEZ, TY DAN (LVN)
Entity type:Individual
Prefix:
First Name:TY
Middle Name:DAN
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3140 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79762-7638
Mailing Address - Country:US
Mailing Address - Phone:432-413-3758
Mailing Address - Fax:
Practice Address - Street 1:11049 W HOFFMAN DR
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79764-9043
Practice Address - Country:US
Practice Address - Phone:432-530-0970
Practice Address - Fax:432-530-0970
Is Sole Proprietor?:No
Enumeration Date:2018-02-19
Last Update Date:2018-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187240164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse