Provider Demographics
NPI:1861767584
Name:BRAD W. RUETENIK, DPM, INC.
Entity type:Organization
Organization Name:BRAD W. RUETENIK, DPM, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUETENIK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-753-1804
Mailing Address - Street 1:249 S HIGHWAY 101
Mailing Address - Street 2:SUITE 408
Mailing Address - City:SOLANA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92075-1807
Mailing Address - Country:US
Mailing Address - Phone:760-753-1804
Mailing Address - Fax:760-942-1895
Practice Address - Street 1:1011 DEVONSHIRE DR
Practice Address - Street 2:SUITE F
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5136
Practice Address - Country:US
Practice Address - Phone:760-753-1804
Practice Address - Fax:760-942-1895
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3866261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU46740Medicare UPIN