Provider Demographics
NPI:1871229161
Name:RODIS, RUBEN R JR
Entity type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:R
Last Name:RODIS
Suffix:JR
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 1:15550 W CAMERON DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-1055
Mailing Address - Country:US
Mailing Address - Phone:623-234-8655
Mailing Address - Fax:623-234-1335
Practice Address - Street 1:15550 W CAMERON DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-1055
Practice Address - Country:US
Practice Address - Phone:623-234-8655
Practice Address - Fax:623-234-1335
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL7402H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility