Healthcare Provider Details

I. General information

NPI: 1720200397
Provider Name (Legal Business Name): RUBY DIANE SMITH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. RUBY DIANE SMITH HARRIS

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 01/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95-1011 PUUKOA ST
MILILANI HI
96789-6505
US

IV. Provider business mailing address

95-1011 PUUKOA ST
MILILANI HI
96789-6505
US

V. Phone/Fax

Practice location:
  • Phone: 863-409-5465
  • Fax:
Mailing address:
  • Phone: 863-409-5465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA 18427
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: