MEDICARE: RITA RAMSIS BOTROS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	XEP910030476	OTHER	CA	BLUE CALIFORNIA

General Provider Information

NPI Number	:	1023751435
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RITA RAMSIS BOTROS

Provider Business Mailing Address
First Line	:	21161 BISON MESA RD APT SUITE
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92507-0025
Country	:	US
Telephone Number	:	909-997-2195
Fax Number	:

Provider Business Practice Location Address
First Line	:	12437 LEWIS ST
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-4673
Country	:	US
Telephone Number	:	714-202-0118
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/14/2022
Last Update Date	:	04/14/2022

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