Individual
DR. RUDOLPH A. THEOBALD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.C.
Contact information
Practice address
6024 SOUTWEST BLVD, FORT WORTH, TX 76109
(817) 665-5495
(817) 524-6194
Mailing address
PO BOX 123525, FORT WORTH, TX 76121-3525
(817) 228-2896
(817) 423-4441
Taxonomy
Speciality
Code
Description
License number
State
111NR0400X
Rehabilitation Chiropractor
Primary
8869
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
104065
AMERIGROUP
TX
01
—
11384841
CAQH
TX
05
—
149696001
—
TX
01
—
1997117
FIRST HEALTH
TX
01
—
606350
BCBS PAR PLAN
TN
Enumeration date
10/25/2006
Last updated
06/21/2023
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