Provider Demographics
NPI:1801563432
Name:RUITER, CHARLES WALTER III
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WALTER
Last Name:RUITER
Suffix:III
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 1:3355 PALMS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-5663
Mailing Address - Country:US
Mailing Address - Phone:702-252-4069
Mailing Address - Fax:
Practice Address - Street 1:3355 PALMS CENTER DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-5663
Practice Address - Country:US
Practice Address - Phone:702-252-4069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB202009141071371225XE0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XE0001XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistEnvironmental Modification
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV9005059132Medicaid