MEDICARE: RUDY HABERZETTL MSPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	6876	CO

General Provider Information

NPI Number	:	1033326749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUDY HABERZETTL MSPT

Provider Business Mailing Address
First Line	:	6965 AMBER RIDGE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80922-2419
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1855 TELSTAR DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1005
Country	:	US
Telephone Number	:	719-310-1741
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/16/2007
Last Update Date	:	07/08/2007

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