Provider Demographics
NPI:1346264165
Name:RUDIN, MITCHELL JAY (LMT)
Entity Type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:JAY
Last Name:RUDIN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11620 NW 28TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3490
Mailing Address - Country:US
Mailing Address - Phone:954-255-9262
Mailing Address - Fax:
Practice Address - Street 1:11620 NW 28TH ST
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-3490
Practice Address - Country:US
Practice Address - Phone:954-255-9262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA19369174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA19369OtherLICENSED MASSAGE THERAPIS