Provider Demographics
NPI:1912199233
Name:PHILLIP RUIZ, LATINA MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:PHILLIP RUIZ, LATINA MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:ADRIAN
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-359-9204
Mailing Address - Street 1:1234 E FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90001-2433
Mailing Address - Country:US
Mailing Address - Phone:323-583-9544
Mailing Address - Fax:323-583-9546
Practice Address - Street 1:1234 E FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90001-2433
Practice Address - Country:US
Practice Address - Phone:323-583-9544
Practice Address - Fax:323-583-9546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44599207Q00000X
CAPA16956261Q00000X
CANP11421261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A445990Medicaid
CA00A445991Medicaid
CA00A445992Medicaid
CA00A445991Medicaid
CAE08456Medicare UPIN