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General NPI Number Information
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NPI Number | 1215200969
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Entity Type | Individual
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Provider Name | GINALYN LACSON RUDER PT
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Gender | Female
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Dates
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Enumeration Date | 02/10/2012
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Last Update Date | 04/12/2017
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Provider Practice Location Address
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Address Line | 401 CORPORATE PARK DR
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City | SAINT LOUIS
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State | MO
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Zip | 63105-4201
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Country | US
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Telephone | 314-725-7447
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Fax |
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Provider Business Mailing Address
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Address Line | 4977 SEIBERT AVE
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City | AFFTON
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State | MO
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Zip | 63123-4736
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Country | US
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Telephone | 314-287-0757
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 2012009718
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070.018896
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License Number State | IL
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