Basic Information
| Provider Information | |||||||||
| NPI: | 1750967535 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDISILL | ||||||||
| FirstName: | DYLAN | ||||||||
| MiddleName: | SHANE | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281444303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009053261 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 PINEVIEW DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272843814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363293295 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2021 | ||||||||
| LastUpdateDate: | 04/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 86074420 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.