Provider Demographics
NPI:1730633165
Name:RUDY, GEOFFREY
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:RUDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 NW 22ND CT
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33311-3741
Mailing Address - Country:US
Mailing Address - Phone:415-420-9504
Mailing Address - Fax:
Practice Address - Street 1:3305 RICE ST
Practice Address - Street 2:
Practice Address - City:COCONUT GROVE
Practice Address - State:FL
Practice Address - Zip Code:33133-5216
Practice Address - Country:US
Practice Address - Phone:415-420-9504
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11861111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor