MEDICARE: MR. MARIO ENRIQUE RUIZ JR.

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	225400000X	Rehabilitation Practitioner
2	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1568594851
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARIO ENRIQUE RUIZ JR.

Provider Business Mailing Address
First Line	:	16782 VON KARMAN AVE STE 11
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92606-2417
Country	:	US
Telephone Number	:	949-833-2237
Fax Number	:

Provider Business Practice Location Address
First Line	:	12465 LEWIS ST STE 102
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-4658
Country	:	US
Telephone Number	:	949-833-2237
Fax Number	:

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

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	12/30/2019

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