Provider Demographics
NPI:1154320653
Name:RUTLEDGE, GARY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:RUTLEDGE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15435 MAIN NE
Mailing Address - Street 2:POST OFFICE BOX 820
Mailing Address - City:DUVALL
Mailing Address - State:WA
Mailing Address - Zip Code:98019-0820
Mailing Address - Country:US
Mailing Address - Phone:425-788-4625
Mailing Address - Fax:425-844-2557
Practice Address - Street 1:15435 MAIN NE
Practice Address - Street 2:
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019-0820
Practice Address - Country:US
Practice Address - Phone:425-788-4625
Practice Address - Fax:425-844-2557
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-18
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA025202CH00001323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA025202CH00001323OtherSTATE LICENSE
WA6011700132OtherUBI
WA6011700132OtherUBI