Provider Demographics
NPI:1770609224
Name:RUDOLPH, MELODY A (BS, CMT, CST, CIMI)
Entity type:Individual
Prefix:
First Name:MELODY
Middle Name:A
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:BS, CMT, CST, CIMI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9968 VIA LESLIE
Mailing Address - Street 2:
Mailing Address - City:SANTEE
Mailing Address - State:CA
Mailing Address - Zip Code:92071-1547
Mailing Address - Country:US
Mailing Address - Phone:619-794-9002
Mailing Address - Fax:
Practice Address - Street 1:10201 MISSION GORGE RD
Practice Address - Street 2:SUITE 'A'
Practice Address - City:SANTEE
Practice Address - State:CA
Practice Address - Zip Code:92071-3027
Practice Address - Country:US
Practice Address - Phone:619-794-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51723174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist