Healthcare Provider Details

I. General information

NPI: 1831241611
Provider Name (Legal Business Name): PAUL RUDD REG DIETICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E 12TH ST
BENTON KY
42025
US

IV. Provider business mailing address

267 SLICKBACK RD
BENTON KY
42025-7629
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-1496
  • Fax: 270-527-5321
Mailing address:
  • Phone: 270-527-1496
  • Fax: 270-252-2737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberKY1534
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: