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General NPI Number Information
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NPI Number | 1750967535
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Entity Type | Individual
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Provider Name | DYLAN SHANE RUDISILL RD
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Gender | Male
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Dates
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Enumeration Date | 03/22/2021
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Last Update Date | 04/02/2021
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Provider Practice Location Address
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Address Line | 500 PINEVIEW DR STE 205
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City | KERNERSVILLE
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State | NC
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Zip | 27284-3814
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Country | US
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Telephone | 336-329-3295
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Fax |
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Provider Business Mailing Address
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Address Line | 501 N MAIN ST
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City | SALISBURY
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State | NC
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Zip | 28144-4303
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Country | US
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Telephone | 800-905-3261
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | 86074420
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License Number State |
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