Basic Information
| Provider Information | |||||||||
| NPI: | 1376007211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUIZ | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | SIMONE | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | RUIZ | ||||||||
| OtherFirstName: | KATRINA | ||||||||
| OtherMiddleName: | SIMONE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7351 W CHARLESTON BLVD STE 120 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891171572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024700620 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7351 W CHARLESTON BLVD STE 120 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891171572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024700620 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2019 | ||||||||
| LastUpdateDate: | 01/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | F5540252 | CA | Y |
No ID Information.