Healthcare Provider Details

I. General information

NPI: 1912913849
Provider Name (Legal Business Name): MATTHEW L. RUIZ CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E WASHINGTON ST STE. 100
COLTON CA
92324-7111
US

IV. Provider business mailing address

11999 SAN VICENTE BLVD STE. 440
LOS ANGELES CA
90049-5131
US

V. Phone/Fax

Practice location:
  • Phone: 909-370-2190
  • Fax:
Mailing address:
  • Phone: 310-440-3131
  • Fax: 310-472-9582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA 3075
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: