Provider Demographics
NPI:1174166698
Name:RODRIGUEZ, BORIS
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
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 1:3365 WYNN RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-8202
Mailing Address - Country:US
Mailing Address - Phone:702-331-3845
Mailing Address - Fax:
Practice Address - Street 1:3365 WYNN RD STE A
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-8202
Practice Address - Country:US
Practice Address - Phone:702-331-3845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No167G00000XNursing Service ProvidersLicensed Psychiatric Technician
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No2472E0500XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherEEG
No374700000XNursing Service Related ProvidersTechnician