Provider Demographics
NPI:1881050961
Name:VITALE, RUTAIRAT
Entity type:Individual
Prefix:MS
First Name:RUTAIRAT
Middle Name:
Last Name:VITALE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2513 TAPO ST
Mailing Address - Street 2:SUITE 5
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-2493
Mailing Address - Country:US
Mailing Address - Phone:805-522-2255
Mailing Address - Fax:
Practice Address - Street 1:2513 TAPO ST
Practice Address - Street 2:SUITE 5
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-2493
Practice Address - Country:US
Practice Address - Phone:805-522-2255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAMTC3131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist