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General NPI Number Information
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NPI Number | 1356401566
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Entity Type | Organization
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Legal Business Name | BONEBUILDERS MEDICAL CLINIC
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 01/07/2022
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Provider Practice Location Address
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Address Line | 4150 REGENTS PARK ROW STE 321
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City | LA JOLLA
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State | CA
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Zip | 92037-9124
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Country | US
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Telephone | 858-678-0455
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Fax | 858-678-0391
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Provider Business Mailing Address
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Address Line | 4510 EXECUTIVE DRIVE SUITE 125
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City | SAN DIEGO
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State | CA
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Zip | 92121
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Country | US
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Telephone | 858-678-0455
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Fax | 858-678-0391
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES N RUDOLPH
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Credential | MD
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Telephone | 858-678-0455
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | G60659
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License Number State | CA
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