Basic Information
Provider Information
NPI: 1003151846
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: RODRIGUEZ
FirstName: ILSA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PASEO DEL PARQUE
Address2: #92 MEDICI ST.
City: SAN JUAN
State: PR
PostalCode: 009266514
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: PASEO DEL PARQUE
Address2: #92 MEDICI ST.
City: SAN JUAN
State: PR
PostalCode: 009266514
CountryCode: US
TelephoneNumber: 7872920627
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/05/2012
LastUpdateDate: 12/05/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X0752PRY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


Home