MEDICARE: HEATHER RUDALAVAGE RD LDN

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	133V00000X	Registered Dietitian	DN004094	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12132775	OTHER	PA	CAQH

General Provider Information

NPI Number	:	1740566751
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEATHER RUDALAVAGE RD LDN

Provider Business Mailing Address
First Line	:	1023 HAWTHORNE LN
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-1736
Country	:	US
Telephone Number	:	215-643-3572
Fax Number	:

Provider Business Practice Location Address
First Line	:	1023 HAWTHORNE LN
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-1736
Country	:	US
Telephone Number	:	215-643-3572
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MRS. HEATHER E RUDALAVAGE
Credential	:	RD
Telephone Number	:	215-643-3572

Provider Enumeration Date	:	10/24/2011
Last Update Date	:	10/24/2011

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