Healthcare Provider Details

I. General information

NPI: 1952607236
Provider Name (Legal Business Name): MR. RUDOLPH WASHINGTON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12501 S WILMINGTON AVE
COMPTON CA
90222-1220
US

IV. Provider business mailing address

3545 W LUTHER LN
INGLEWOOD CA
90305-1886
US

V. Phone/Fax

Practice location:
  • Phone: 310-462-0821
  • Fax:
Mailing address:
  • Phone: 310-462-0821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10302
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: