Provider Demographics
NPI:1831241611
Name:RUDD, PAUL (REG DIETICIAN)
Entity type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:RUDD
Suffix:
Gender:M
Credentials:REG DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:267 SLICKBACK RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-7629
Mailing Address - Country:US
Mailing Address - Phone:270-527-1496
Mailing Address - Fax:270-252-2737
Practice Address - Street 1:307 E 12TH ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025
Practice Address - Country:US
Practice Address - Phone:270-527-1496
Practice Address - Fax:270-527-5321
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY1534133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20079018Medicaid
KY20079018Medicaid