Provider Demographics
NPI:1477901403
Name:WALLINGSFORD, RUBY ROSE (OTR)
Entity Type:Individual
Prefix:
First Name:RUBY
Middle Name:ROSE
Last Name:WALLINGSFORD
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 N WARE RD
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78501-3305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3201 N WARE RD
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78501-3305
Practice Address - Country:US
Practice Address - Phone:956-631-5542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110799314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility