Healthcare Provider Details

I. General information

NPI: 1245524586
Provider Name (Legal Business Name): DRAGILY RYUCER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHRISTIAN RONQUILLO

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 12/15/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 KOKOMO DR APT 1013
SACRAMENTO CA
95835-1826
US

IV. Provider business mailing address

PO BOX 348011
SACRAMENTO CA
95834-8011
US

V. Phone/Fax

Practice location:
  • Phone: 510-761-0214
  • Fax:
Mailing address:
  • Phone: 510-761-0214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105867
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: