Provider Demographics
NPI:1184017709
Name:RUIZ, SAMANTHA I
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:I
Last Name:RUIZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1789 MINAS DE ORO
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95116-1355
Mailing Address - Country:US
Mailing Address - Phone:408-417-4160
Mailing Address - Fax:
Practice Address - Street 1:1789 MINAS DE ORO
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95116-1355
Practice Address - Country:US
Practice Address - Phone:408-417-4160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1568258172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker