Healthcare Provider Details

I. General information

NPI: 1720821978
Provider Name (Legal Business Name): TARRAH RUIZ DE LUZURIAGA RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 07/26/2024
Certification Date: 07/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N HAYWORTH AVE
LOS ANGELES CA
90048-2702
US

IV. Provider business mailing address

4151 TRENT WAY
LOS ANGELES CA
90065-3806
US

V. Phone/Fax

Practice location:
  • Phone: 310-390-9045
  • Fax:
Mailing address:
  • Phone: 310-402-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number302486
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT302486
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: