Healthcare Provider Details

I. General information

NPI: 1740937234
Provider Name (Legal Business Name): STACEY RUANO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 N WESTERN AVE
LOS ANGELES CA
90027-5615
US

IV. Provider business mailing address

1325 N WESTERN AVE
LOS ANGELES CA
90027-5615
US

V. Phone/Fax

Practice location:
  • Phone: 323-461-3131
  • Fax:
Mailing address:
  • Phone: 323-461-3131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: