Healthcare Provider Details

I. General information

NPI: 1851932099
Provider Name (Legal Business Name): BACILIO RUIZ PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2019
Last Update Date: 10/25/2024
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

1801 ORANGE TREE LN
REDLANDS CA
92374-4589
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1775
  • Fax:
Mailing address:
  • Phone: 909-557-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA57725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: