Healthcare Provider Details

I. General information

NPI: 1700937778
Provider Name (Legal Business Name): AMANDA RUIZ, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8700 BEVERLY BLVD THALIANS, SUITE E123-D
WEST HOLLYWOOD CA
90048-1804
US

IV. Provider business mailing address

P.O. BOX 1309
STUDIO CITY CA
92138-7972
US

V. Phone/Fax

Practice location:
  • Phone: 858-344-8016
  • Fax:
Mailing address:
  • Phone: 858-344-8016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA67430
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberA67430
License Number StateCA

VIII. Authorized Official

Name: DR. AMANDA RUIZ GRAVES
Title or Position: CEO
Credential: M.D.
Phone: 858-344-8016