Healthcare Provider Details

I. General information

NPI: 1073249496
Provider Name (Legal Business Name): MARIO ANTHONY RUELAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2022
Last Update Date: 05/30/2025
Certification Date: 05/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 N 1ST ST
SAN JOSE CA
95112-5319
US

IV. Provider business mailing address

1027 CLINTONIA AVE
SAN JOSE CA
95125-2209
US

V. Phone/Fax

Practice location:
  • Phone: 408-261-7777
  • Fax: 408-259-2273
Mailing address:
  • Phone: 408-499-6413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: