Provider Demographics
NPI:1144083312
Name:RODRIGUEZ, KEVIN J (RDN)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:RODRIGUEZ
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6349 AVENIDA DE LAS VISTAS UNIT 4
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-6610
Mailing Address - Country:US
Mailing Address - Phone:619-395-6921
Mailing Address - Fax:
Practice Address - Street 1:6349 AVENIDA DE LAS VISTAS UNIT 4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-6610
Practice Address - Country:US
Practice Address - Phone:619-395-6921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86119743133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered