Provider Demographics
NPI:1457800609
Name:ECHEVERRIA, RUBEN
Entity Type:Individual
Prefix:MR
First Name:RUBEN
Middle Name:
Last Name:ECHEVERRIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2756 DONNER TRL
Mailing Address - Street 2:
Mailing Address - City:RIVERBANK
Mailing Address - State:CA
Mailing Address - Zip Code:95367-9583
Mailing Address - Country:US
Mailing Address - Phone:209-408-3398
Mailing Address - Fax:
Practice Address - Street 1:1212 CALIFORNIA ST.
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-468-8886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 36928167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician