Basic Information
| Provider Information | |||||||||
| NPI: | 1760013858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GO | ||||||||
| FirstName: | FREDERICK JOHN | ||||||||
| MiddleName: | RUIZ | ||||||||
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| Credential: | BSN-RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16026 GARRETT CT | ||||||||
| Address2: | |||||||||
| City: | LA PUENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917441300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264136427 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 210 W SAN BERNARDINO RD | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917231515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269387650 | ||||||||
| FaxNumber: | 6268595848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2020 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0809X | 559326 | CA | Y | Nursing Service Providers | Registered Nurse | Psych/Mental Health, Adult |
No ID Information.