Provider Demographics
NPI:1750563417
Name:RODRIGUEZ, ARACELLI (BA)
Entity type:Individual
Prefix:MRS
First Name:ARACELLI
Middle Name:
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 E 17TH ST STE 365
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6497
Mailing Address - Country:US
Mailing Address - Phone:208-403-2825
Mailing Address - Fax:208-542-5152
Practice Address - Street 1:1820 E 17TH ST STE 365
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6497
Practice Address - Country:US
Practice Address - Phone:208-403-2825
Practice Address - Fax:208-542-5152
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID8078763171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8078763Medicare PIN