Provider Demographics
NPI:1538515424
Name:RUIZ, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:983 CALLE MADRID APT 28
Mailing Address - Street 2:URB SANTA RITA
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00925-0092
Mailing Address - Country:US
Mailing Address - Phone:787-641-7582
Mailing Address - Fax:
Practice Address - Street 1:983 CALLE MADRID
Practice Address - Street 2:APT 28 URB. SANTA RITA
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00925-2647
Practice Address - Country:US
Practice Address - Phone:787-641-7582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1069648133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered