Provider Demographics
NPI:1720290414
Name:RUDELL, SCOTT ALEXANDER SR (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ALEXANDER
Last Name:RUDELL
Suffix:SR
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 1:315 E COTATI AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931
Mailing Address - Country:US
Mailing Address - Phone:707-795-0057
Mailing Address - Fax:707-795-9517
Practice Address - Street 1:315 E COTATI AVE
Practice Address - Street 2:SUITE E
Practice Address - City:COTATI
Practice Address - State:CA
Practice Address - Zip Code:94931
Practice Address - Country:US
Practice Address - Phone:707-795-0057
Practice Address - Fax:707-795-9517
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11369111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC0113690Medicare ID - Type Unspecified