Provider Demographics
NPI:1376909135
Name:RUDDLE, KRISTINA (DC)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:RUDDLE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 COUNTRY CLUB PARC CT
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-3626
Mailing Address - Country:US
Mailing Address - Phone:314-775-5396
Mailing Address - Fax:
Practice Address - Street 1:4455 TELEGRAPH RD STE 250
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-3354
Practice Address - Country:US
Practice Address - Phone:314-416-4900
Practice Address - Fax:314-487-4669
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-10
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016000080111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor