Provider Demographics
NPI:1770648388
Name:RUDDELL, BRIAN T (DC)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:T
Last Name:RUDDELL
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 1:1117 16TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501
Mailing Address - Country:US
Mailing Address - Phone:208-743-8401
Mailing Address - Fax:208-743-8722
Practice Address - Street 1:1117 16TH AVENUE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501
Practice Address - Country:US
Practice Address - Phone:208-743-8401
Practice Address - Fax:208-743-8722
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA503111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDC5030OtherBLUESCROSS
ID000010018610OtherREGENCE
38266OtherDEPT OF LABOR AND INDUSTR
IDC5030OtherBLUESCROSS