Provider Demographics
NPI:1548266646
Name:PATEL, RUTAMBHAR (DC)
Entity type:Individual
Prefix:DR
First Name:RUTAMBHAR
Middle Name:
Last Name:PATEL
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 1:122 LINCOLN BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-2826
Mailing Address - Country:US
Mailing Address - Phone:310-399-3200
Mailing Address - Fax:
Practice Address - Street 1:122 LINCOLN BLVD
Practice Address - Street 2:STE 103
Practice Address - City:VENICE
Practice Address - State:CA
Practice Address - Zip Code:90291-2826
Practice Address - Country:US
Practice Address - Phone:310-399-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC25916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC25916AMedicare ID - Type Unspecified