Provider Demographics
NPI:1891200069
Name:TUDOR, GEORGE (LMT,BCTMB,SI,)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:TUDOR
Suffix:
Gender:M
Credentials:LMT,BCTMB,SI,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19633 BLUE BIRD LN UNIT 7
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-6130
Mailing Address - Country:US
Mailing Address - Phone:302-727-8428
Mailing Address - Fax:
Practice Address - Street 1:19633 BLUE BIRD LN UNIT 7
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-6130
Practice Address - Country:US
Practice Address - Phone:302-727-8428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0003121225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE585208-09OtherNCBTMB