Provider Demographics
NPI:1740466325
Name:R RUIZ M D A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:R RUIZ M D A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUBEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-201-2508
Mailing Address - Street 1:833 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4735
Mailing Address - Country:US
Mailing Address - Phone:323-712-4811
Mailing Address - Fax:844-302-8678
Practice Address - Street 1:833 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4735
Practice Address - Country:US
Practice Address - Phone:323-712-4811
Practice Address - Fax:844-302-8678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALAB79356F291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2160409OtherCLIA CERTIFICATE OF WAIVER
CALAB79356FMedicaid