Healthcare Provider Details

I. General information

NPI: 1386469427
Provider Name (Legal Business Name): MARIO RUIZ PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 W FOOTHILL BLVD STE 200
CLAREMONT CA
91711-3475
US

IV. Provider business mailing address

1004 W WEST COVINA PKWY # 477
WEST COVINA CA
91790-2810
US

V. Phone/Fax

Practice location:
  • Phone: 925-282-1778
  • Fax:
Mailing address:
  • Phone: 323-947-1167
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95030403
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95214650
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: