Basic Information
| Provider Information | |||||||||
| NPI: | 1518436948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUELAS-ORTEGA | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | MAGALY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 49 BLANCA LN SPC 54 | ||||||||
| Address2: | |||||||||
| City: | WATSONVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950762124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8317073448 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3650 MT DIABLO BLVD STE 107 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945493780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106659700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2018 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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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 | 106S00000X | CA | Y |
ID Information
| ID | Type | State | Issuer | Description | 90865741D | 05 | CA | MEDICAID |