Provider Demographics
NPI:1912036732
Name:RUDY ORTHOMEDIC, CORP
Entity Type:Organization
Organization Name:RUDY ORTHOMEDIC, CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RODOLFO
Authorized Official - Middle Name:E
Authorized Official - Last Name:GUERRA
Authorized Official - Suffix:
Authorized Official - Credentials:OP
Authorized Official - Phone:787-262-5000
Mailing Address - Street 1:125 AVE F. D. ROOSEVELT
Mailing Address - Street 2:
Mailing Address - City:HATILLO
Mailing Address - State:PR
Mailing Address - Zip Code:00659-1855
Mailing Address - Country:US
Mailing Address - Phone:787-262-5000
Mailing Address - Fax:787-262-7000
Practice Address - Street 1:125 AVE F. D. ROOSEVELT
Practice Address - Street 2:
Practice Address - City:HATILLO
Practice Address - State:PR
Practice Address - Zip Code:00659-1855
Practice Address - Country:US
Practice Address - Phone:787-262-5000
Practice Address - Fax:787-262-7000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1912036732332B00000X
OHOP-7621335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR5223620001Medicare NSC