=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407838675
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAMIEN JUDE RODULFO DC, CCSP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2005
-----------------------------------------------------
Last Update Date | 04/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2105 W CORNWALLIS DR STE C A
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-7098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-235-4530
-----------------------------------------------------
Fax | 336-235-0754
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2105 W CORNWALLIS DR STE C
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27408-7098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-235-4530
-----------------------------------------------------
Fax | 336-235-0754
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111NS0005X
-----------------------------------------------------
Taxonomy Name | Sports Physician Chiropractor
-----------------------------------------------------
License Number | 3242
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------