Healthcare Provider Details

I. General information

NPI: 1205343282
Provider Name (Legal Business Name): EDGAR O. RUANO MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CESERY BLVD STE 100
JACKSONVILLE FL
32211-5656
US

IV. Provider business mailing address

791 ASSISI LN APT 905
JACKSONVILLE FL
32233-6802
US

V. Phone/Fax

Practice location:
  • Phone: 904-448-4700
  • Fax:
Mailing address:
  • Phone: 626-392-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: