Healthcare Provider Details

I. General information

NPI: 1922648799
Provider Name (Legal Business Name): JONATHAN RUIZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6930 W TOUHY AVE
NILES IL
60714-4522
US

IV. Provider business mailing address

9332 MORGAN AVE
EVANSTON IL
60203-1418
US

V. Phone/Fax

Practice location:
  • Phone: 847-647-0003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: