Provider Demographics
NPI:1760785588
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:LABORATORY DIRECTOR
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:909-877-0008
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:2010-12-16
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACLA 328915291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACLA 328915OtherCLINICAL LABORATORY LICENSE
CA05D0994683OtherCLIA CERTIFICATE OF WAIVER