Provider Demographics
NPI:1790317139
Name:RUIZ, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
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 1:100 WILKINSON RD
Mailing Address - Street 2:
Mailing Address - City:MACEDON
Mailing Address - State:NY
Mailing Address - Zip Code:14502-9713
Mailing Address - Country:US
Mailing Address - Phone:315-398-0148
Mailing Address - Fax:
Practice Address - Street 1:953 DANBY RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-7000
Practice Address - Country:US
Practice Address - Phone:315-398-0148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer