Provider Demographics
NPI:1215079207
Name:BREILEIN, RUDOLPH RAYMOND
Entity type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:RAYMOND
Last Name:BREILEIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 S MENTOR AVE
Mailing Address - Street 2:#112
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2927
Mailing Address - Country:US
Mailing Address - Phone:626-731-0547
Mailing Address - Fax:
Practice Address - Street 1:70 N HUDSON AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91101-1808
Practice Address - Country:US
Practice Address - Phone:626-795-8471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21287167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician