Provider Demographics
NPI:1679577290
Name:RUDNICK, WAYNE L (DC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:L
Last Name:RUDNICK
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 1:570 N COLUMBUS BLVD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-2957
Mailing Address - Country:US
Mailing Address - Phone:520-323-8989
Mailing Address - Fax:520-327-9751
Practice Address - Street 1:570 N COLUMBUS BLVD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2957
Practice Address - Country:US
Practice Address - Phone:520-323-8989
Practice Address - Fax:520-327-9751
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2018-12-12
Deactivation Date:2006-03-16
Deactivation Code:
Reactivation Date:2006-04-25
Provider Licenses
StateLicense IDTaxonomies
AZ5512111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0244490OtherBLUE CROSS BLUE SHIELD
Z62053Medicare ID - Type Unspecified
U68142Medicare UPIN