Provider Demographics
NPI:1578599809
Name:R RUIZ M D A MEDICAL CORP
Entity Type:Organization
Organization Name:R RUIZ M D A MEDICAL CORP
Other - Org Name:RIALTO CLINICA MEDICA FAMILIAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-201-2508
Mailing Address - Street 1:436 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-6523
Mailing Address - Country:US
Mailing Address - Phone:909-877-8868
Mailing Address - Fax:
Practice Address - Street 1:436 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6523
Practice Address - Country:US
Practice Address - Phone:909-877-8868
Practice Address - Fax:909-877-0008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52245174400000X
208000000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0060100Medicaid
CAGR0060100Medicaid