Provider Demographics
NPI:1629803697
Name:RUSTIC CANTEEN, LLC
Entity type:Organization
Organization Name:RUSTIC CANTEEN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-463-0603
Mailing Address - Street 1:22 PASADA VALIENTE
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-1983
Mailing Address - Country:US
Mailing Address - Phone:949-463-0603
Mailing Address - Fax:
Practice Address - Street 1:6465 W COLFAX AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80214-1801
Practice Address - Country:US
Practice Address - Phone:949-463-0603
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-07
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals