Healthcare Provider Details

I. General information

NPI: 1407446628
Provider Name (Legal Business Name): NICKODEM RUDZINSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2021
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 CAPP ST
SAN FRANCISCO CA
94110-3225
US

IV. Provider business mailing address

368 FELL ST
SAN FRANCISCO CA
94102-5144
US

V. Phone/Fax

Practice location:
  • Phone: 415-285-0810
  • Fax:
Mailing address:
  • Phone: 415-861-0828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: