Healthcare Provider Details

I. General information

NPI: 1043708951
Provider Name (Legal Business Name): RUDOLPH CHRISTOS TESCALLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 B ST
SANTA ROSA CA
95401-5211
US

IV. Provider business mailing address

11 BRENGLE CT
PETALUMA CA
94954-5844
US

V. Phone/Fax

Practice location:
  • Phone: 707-579-0465
  • Fax:
Mailing address:
  • Phone: 707-849-1896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: