Healthcare Provider Details

I. General information

NPI: 1689141889
Provider Name (Legal Business Name): KIRI J RUTLEDGE OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

551 NATIONAL HEALTH CARE DR
DAYTONA BEACH FL
32114-1495
US

IV. Provider business mailing address

730 S WASHINGTON AVE
TITUSVILLE FL
32780-4232
US

V. Phone/Fax

Practice location:
  • Phone: 386-323-7500
  • Fax:
Mailing address:
  • Phone: 321-267-2020
  • Fax: 321-267-4165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC5636
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: