Healthcare Provider Details

I. General information

NPI: 1023234754
Provider Name (Legal Business Name): RUDOLPH GARZA PLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1152 BURTON ST SE
GRAND RAPIDS MI
49507-3359
US

IV. Provider business mailing address

1152 BURTON SE
GRAND RAPIDS MI
49507
US

V. Phone/Fax

Practice location:
  • Phone: 616-475-7830
  • Fax:
Mailing address:
  • Phone: 616-475-7830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0013X
TaxonomyIndependent Medical Examiner Chiropractor
License Number23010005627
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: