Provider Demographics
NPI:1831217462
Name:RUDOLPH, ALLEN EDWARD (DC)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:EDWARD
Last Name:RUDOLPH
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 1:1839 E CAPITOL AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-5617
Mailing Address - Country:US
Mailing Address - Phone:507-380-6812
Mailing Address - Fax:
Practice Address - Street 1:1839 E CAPITOL AVE STE B
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501
Practice Address - Country:US
Practice Address - Phone:701-369-3938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4016111N00000X
ND887111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND887OtherSTATE LICENSE
ND17325Medicaid