Basic Information
| Provider Information | |||||||||
| NPI: | 1033772355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARAVEO RUIZ | ||||||||
| FirstName: | MIKAILA | ||||||||
| MiddleName: | RENAE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4533 S 236TH DR | ||||||||
| Address2: | |||||||||
| City: | BUCKEYE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853267431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6236067045 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 ROSE LN | ||||||||
| Address2: | |||||||||
| City: | WICKENBURG | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853901447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286845529 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2019 | ||||||||
| LastUpdateDate: | 04/22/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA-013815 | AZ | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.