Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | ||
N | 225400000X | Rehabilitation Practitioner |
NPI | 1043718737 |
---|---|
Provider Name | Roberto Ruiz |
First Address | Lynwood, CA 90262-1713 |
Second Address | Los Angeles, CA 90005-1355 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/01/2018 |
Last Update Date | 06/11/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1043718737 | (05) | CA |
1043718737 | TRAINEE (01) |