Basic Information
| Provider Information | |||||||||
| NPI: | 1336425107 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUELAS | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | REGINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR/L | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BACH | ||||||||
| OtherFirstName: | CARLA | ||||||||
| OtherMiddleName: | REGINA | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | OTR/L | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2618 NW 11TH ST | ||||||||
| Address2: | |||||||||
| City: | BATTLE GROUND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986043253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3609898802 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 SE PARK CREST AVE | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986831300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602602200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2011 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | OT00004130 | WA | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.