Provider Demographics
NPI:1740452259
Name:HORST R. RUDRICH MEDICAL CORPORATION
Entity type:Organization
Organization Name:HORST R. RUDRICH MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HORST
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUDRICH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-798-3061
Mailing Address - Street 1:1574 EDGEHILL LN
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6523
Mailing Address - Country:US
Mailing Address - Phone:909-798-3061
Mailing Address - Fax:909-798-1221
Practice Address - Street 1:255 TERRACINA BLVD
Practice Address - Street 2:STE. 105
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-793-0323
Practice Address - Fax:909-793-9173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA080190100OtherMEDICARE RAILROAD
CA020A59701OtherMEDICARE ID
CA00AX59700Medicaid
CAF15538Medicare UPIN