Provider Demographics
NPI:1881286730
Name:RUDOMETKINA, IRINA IGOREVNA (COTA/L)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:IGOREVNA
Last Name:RUDOMETKINA
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 FOURNESS DR
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-2225
Mailing Address - Country:US
Mailing Address - Phone:916-477-9700
Mailing Address - Fax:
Practice Address - Street 1:3498 GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:RESCUE
Practice Address - State:CA
Practice Address - Zip Code:95672-9625
Practice Address - Country:US
Practice Address - Phone:530-391-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5255224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant