Basic Information
| Provider Information | |||||||||
| NPI: | 1043718737 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUIZ | ||||||||
| FirstName: | ROBERTO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2633 111TH ST | ||||||||
| Address2: | |||||||||
| City: | LYNWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902621713 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 679 S NEW HAMPSHIRE AVE | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900051355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2136392660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2018 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YP2500X | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 1043718737 | 01 | TRAINEE | OTHER | 1043718737 | 05 | CA | MEDICAID |