Healthcare Provider Details

I. General information

NPI: 1447362058
Provider Name (Legal Business Name): RONALD D FUDALA DC,DACAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PLANTATION ISLAND DR S SUITE 402 A
SAINT AUGUSTINE FL
32080-3108
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S SUITE 402A
SAINT AUGUSTINE FL
32080-3108
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-4744
  • Fax: 901-471-4745
Mailing address:
  • Phone: 904-471-4744
  • Fax: 904-471-4745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number1317
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License NumberCH10979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: