Provider Demographics
NPI:1538810775
Name:RUDBERG, KEVIN N (DC)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:N
Last Name:RUDBERG
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 1:1870 HIGHCREST DR
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-5313
Mailing Address - Country:US
Mailing Address - Phone:314-330-5707
Mailing Address - Fax:
Practice Address - Street 1:134 ENCHANTED PKWY STE 104
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:MO
Practice Address - Zip Code:63021-5495
Practice Address - Country:US
Practice Address - Phone:636-277-8888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022000751111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor