Provider Demographics
NPI:1770517047
Name:RUDA, JOHN (DC)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUDA
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 1:130 S HALCYON RD # B
Mailing Address - Street 2:
Mailing Address - City:ARROYO GRANDE
Mailing Address - State:CA
Mailing Address - Zip Code:93420-3116
Mailing Address - Country:US
Mailing Address - Phone:805-481-8508
Mailing Address - Fax:
Practice Address - Street 1:130 S HALCYON RD # B
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-3116
Practice Address - Country:US
Practice Address - Phone:805-481-8508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC22148111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0221480Medicaid
CADC22148Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER