Provider Demographics
NPI:1548987498
Name:RODRIGUES, SOPHIE GRACE (RD)
Entity type:Individual
Prefix:
First Name:SOPHIE
Middle Name:GRACE
Last Name:RODRIGUES
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4210 RIVERWALK PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3313
Mailing Address - Country:US
Mailing Address - Phone:951-358-5311
Mailing Address - Fax:
Practice Address - Street 1:5475 CANYON CREST DR APT 34
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-6436
Practice Address - Country:US
Practice Address - Phone:661-609-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-21
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86114517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered