Healthcare Provider Details

I. General information

NPI: 1558874487
Provider Name (Legal Business Name): DANIEL ROBERT RUDOLPH DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32261 CAMINO CAPISTRANO STE D101
SAN JUAN CAPISTRANO CA
92675-3747
US

IV. Provider business mailing address

26571 NORMANDALE DR APT 17C
LAKE FOREST CA
92630-6768
US

V. Phone/Fax

Practice location:
  • Phone: 949-429-2155
  • Fax:
Mailing address:
  • Phone: 732-232-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number294068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: