1578599809 NPI number — R RUIZ M D A MEDICAL CORP

Table of content: (NPI 1578599809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578599809 NPI number — R RUIZ M D A MEDICAL CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
R RUIZ M D A MEDICAL CORP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
RIALTO CLINICA MEDICA FAMILIAR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578599809
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
436 S RIVERSIDE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIALTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92376-6523
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-877-8868
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
436 S RIVERSIDE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIALTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92376-6523
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-877-8868
Provider Business Practice Location Address Fax Number:
909-877-0008
Provider Enumeration Date:
06/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUIZ
Authorized Official First Name:
RUBEN
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/PRESIDENT
Authorized Official Telephone Number:
562-201-2508

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  G52245 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: GR0060100 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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