Provider Demographics
NPI:1205695947
Name:RUIZ-VELASCO, LUIS MANUEL (RD)
Entity type:Individual
Prefix:MR
First Name:LUIS
Middle Name:MANUEL
Last Name:RUIZ-VELASCO
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:217 S LARK ELLEN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1825
Mailing Address - Country:US
Mailing Address - Phone:626-500-9026
Mailing Address - Fax:
Practice Address - Street 1:3440 E LA PALMA AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92806-2020
Practice Address - Country:US
Practice Address - Phone:626-500-9026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-15
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86171051133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty