Provider Demographics
NPI:1861183915
Name:RODRIGUEZ, EMILY DIANE (ABOC, NCLEC, LDO)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:DIANE
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:ABOC, NCLEC, LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 BATTLEFIELD PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-4004
Mailing Address - Country:US
Mailing Address - Phone:706-861-5622
Mailing Address - Fax:706-861-5704
Practice Address - Street 1:3040 BATTLEFIELD PKWY
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4004
Practice Address - Country:US
Practice Address - Phone:706-861-5622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002850156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician